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MANUAL 



OF 



PATHOLOGICAL ANATOMY. 




C. HANDFIELD JONES, M.B., F.R.S., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, ASSISTANT PHYSICIAN TO, AND LECTURER 
ON PHYSIOLOGY AT, ST. MARY'S HOSPITAL J 

AND 

EDWARD H. SIEVEKXNG, M.D., 

FELLOW OF THE ROYAL COLLEGE OF PHYsiciANS, ASSISTANT PHYSICIAN TO, AND LECTURER 
ON MATERIA MEDICA AT, ST. MARY'S HOSPITAL. 



FIRST AMERICAN EDITION REVISED, 



THREE HUNDRED AND NINETY-SEVEN ILLUSTRATIONS. 




PHILADELPHIA: 
BLANCHARD AND LEA 

1854. 



Entered according to the Act of Congress, in the year 1854, by 

B LAN CHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States, in and for 
the Eastern District of the State of Pennsylvania. 



PHILADELPHIA: 
T. K. AM) P. G. COLLINS, PRINTERS. 



PUBLISHERS' ADVERTISEMENT. 



In a work like the present, intended as a text-book for the student 
of pathology, accurate engravings of the various results of morbid 
action are of the greatest assistance. The publishers have, therefore, 
considered that the value of the work might be enhanced by increasing 
the number of illustrations, and, with this object, many wood-cuts, 
from the best authorities, have been introduced, increasing the number 
from 167, in the London edition, to 397 in this. In the list of illus- 
trations, these additional cuts will be found distinguished by an 
asterisk (*) from those for which the authors are alone responsible. 
The selection of these wood-cuts has been made by a competent mem- 
ber of the profession, who has supervised the progress of the work 
through the press, with the view of securing an accurate reprint, and 
of correcting such errors as had escaped the attention of the authors. 
He has also added, at page 197, an account of the interesting micro- 
scopical observations of Dr. Donaldson, of Baltimore, on the charac- 
teristics of the true cancer-cell. 

Philadelphia, November 1854. 



PREFATORY NOTICE 



The Authors of the present work have desired to lay before their 
professional brethren an outline of what is known in the domain of 
Pathological Anatomy. The absence of any original work in the 
English language, which embraces the whole subject, must be their 
apology for having made the attempt. They have sought to place 
before the reader a summary of ascertained facts, together with the 
opinions of the most eminent pathologists of this and other countries. 
They have regarded it as their duty to select, as far as possible, the 
best fruits from the harvest gathered by other laborers in this wide 
and interesting field. At the same time they have sought not to 
speak solely on the faith of others, even the highest authorities, but 
to investigate, as much as possible, for themselves, the correctness of 
the statements they adopted. They felt that, in some instances, better 
illustrations might have been obtained by borrowing from other works ; 
but they were of opinion that the present manual would bear a stamp 
of greater truthfulness if the drawings were taken from objects seen 
and examined by themselves. They have therefore preferred (with 
few exceptions only) to use such illustrations as their own portfolios 
supplied. Although small drawings, in black and white, necessarily 
fail to give the important elements of size and color, almost essential 
to illustrations of Pathological Anatomy, the Authors hope that the 
masterly treatment of Mr. Bagg has achieved as much as could be 
done by wood engraving. They have divided the subject in the 
manner indicated in the Table of Contents, and are each individually 
responsible for the chapters which they have treated. 



VI PKEFATORY NOTICE. 

They conclude by expressing a hope that the vast extent of the 
subject, and of the material they had to deal with, will serve, in some 
measure, as an apology for the deficiencies which they are fully con- 
scious of, and for which they ask the kind and lenient consideration 
of the Medical Profession. 

C. HANDFIELD JONES, 

EDWARD H. SIEYEKING. 

London, August 5, 1854. 



CONTENTS 



GENERAL PATHOLOGICAL ANATOMY. 

BY C. HANDFIELD JONES. 



General Observations 



Morbid States of the Blood 



Textural Changes 



New Formations — Tumors 



CHAPTER I. 



CHAPTER II. 



CHAPTER III. 



CHAPTER IV. 



VAGB 

83 



52 



161 



1G6 



CHAPTER V. 



Parasites 



213 



PATHOLOGICAL ANATOMY OF THE NERVOUS SYSTEM. 

BY EDWARD H. SIEVEKING. 



General Observations 



The Dura Mater 



CHAPTER VI. 



CHAPTER VII 



. 225 



CHAPTER VIII. 



The Arachnoid and Pia Mater 



230 



CHAPTER IX 



The Brain 



247 



CHAPTER X. 



The Brain (Continued) 



262 



Vlll 



CONTENTS. 



CHAPTER XI. 

The Spinal Cord and its Membranes . , 

CHAPTER XII. 

The Arachnoid and Pia Mater of the Spinal Cord . 



PAGE 

. 268 



. 271 



CHAPTER XIII. 



The Spinal Cord 



. 274 



CHAPTER XIV, 



The Nerves . 



279 



CHAPTER XV. 



The Sympathetic System 



285 



PATHOLOGICAL ANATOMY OF THE ORGANS OF 
CIRCULATION. 



BY EDWARD H. SIEVEKING. 



General Observations 



CHAPTER XVI. 



286 



The Pericardium 



CHAPTER XVII. 



289 



The Heart . 



CHAPTER XVIII. 



296 



The Heart {Continued) 



CHAPTER XIX. 



302 



The Endocardium 



CHAPTER XX. 



313 



The Valves 



CHAPTER XXI. 



319 



The Bloodvessels 



CHAPTER XXII. 



331 



Aneurhm 



CHAPTER XXIII 



344 



CONTENTS. IX 



CHAPTER XXIV. 

PAGE 

The Veins 353 

CHAPTER XXV. 
The Lymphatic System ........ 367 



PATHOLOGICAL ANATOMY OF THE ORGANS OF 
RESPIRATION. 

BY EDWARD H. SIEVEEJNG. 

CHAPTER XXVI. 

General Observations — The Epiglottis — The Larynx — The Trachea . . 373 

CHAPTER XXVII. 

The Bronchial Tubes ........ 384 

CHAPTER XXVIII. 

The Lungs .......... 393 

CHAPTER XXIX. 

The Lungs [Continued) ........ 405 

CHAPTER XXX. 

The Lungs {Continued) . . . . . . . .417 

CHAPTER XXXI. 
The Pleura .......... 434 



PATHOLOGICAL ANATOMY OF THE ALIMENTARY CANAL. 

BY C. HANDHELD JONES. 

CHAPTER XXXII. 

The Mouth and Fauces — The Teeth — The Pharynx and (Esophagus — The Perito- 
neum — The Stomach — The Intestinal Canal — The Intestinal Contents . . 447 

CHAPTER XXXIII. 

The Liver— The Biliary Passages— The Bile . . . . .507 

CHAPTER XXXIV. 

The Pancreas, and the other Salivary Glands— The Ductless Glands— The Thyroid 
Glands .......... 531 



X CONTENTS. 

PATHOLOGICAL ANATOMY OF THE URINARY APPARATUS. 

BY C. HANDFIELD JONES. 

CHAPTER XXXV. 

PAGE 

The Kidney— The Urinary Passages— The Bladder— The Urethra— The Urine . 543 

CHAPTER XXXVI. 
The Male Generative Organs ....... 585 



PATHOLOGICAL ANATOMY OF THE FEMALE ORGANS 
OF GENERATION. 

BY EDWARD H. SIEVEKING. 

CHAPTER XXXVII. 
The External Organs of Generation — The Vagina ..... 607 

CHAPTER XXXVIII. 
The Internal Organs of Generation ...... 614 

CHAPTER XXXIX. 
Morbid Conditions following and preceding Parturition .... 629 

CHAPTER XL. 
The Ovaries — The Mammse ....... 644 



PATHOLOGICAL ANATOMY OF THE JOINTS. 

BY C. HANDFIELD JONES. 

CHAPTER XLI. 
Disease of the Joints ........ 659 



PATHOLOGICAL ANATOMY OF THE OSSEOUS SYSTEM. 

BY EDWARD H. SIEVEE3NG. 

CHAPTER XLII. 
Periosteum — Bone ......... 681 

CHAPTER XLIII. 
Adventitious Growths . . ...... 704 



LIST OF ILLUSTRATIONS 



THOSE MARKED WITH AN ASTERISK HAVE BEEN ADDED BY THE AMERICAN EDITOR. 
TlfJ. 

1.* Blood-corpuscles 

2.* White corpuscles of the blood 

3.* Blood-corpuscles 

4. Fibrils of healthy fibrin 

5. Corpuscular unhealthy fibrin 

6. Softening fibrin from a vein-clot 
ST.* Cholesterin .... 
8.* Fat in blood .... 
9. Contracted artery 

10. Hasmatin crystals 

11.* Changes in blood-globules 

12.* Web in the foot of a frog inflamed 

13. Production of stasis 

14. Fibrinous exudation on pleura in process of absorption 
15.* Commencing organization in effused fibrin 
16. Corpuscles from a pustule 
17.* Pus-globules .... 
18.* Natural appearance of pus-corpuscles 
19.* Pus-corpuscles magnified 
20.* Healthy pus-cells 
21.* "J 

22.* > Various forms of pus-cell 
23* J 
24.* Muco-purulent matter 

25. G-lomeruli and granulous cells . 

26. Separate corpuscles and two blood-globules 

27. Blood in leucocythaemia 

28. Cray tubercle ; miliary granulation 

29. Yellow tubercle; crude mass 

30. Isolated tubercle corpuscles 
31.* Tubercle corpuscles from the peritoneum 
32.* Tubercle corpuscles, granules, and molecules, from the lun 
33.* Tubercle corpuscles from a mesenteric gland 
34.* Tubercle corpuscles from the lung 
35.* Pus-corpuscles ..... 
36.* Plastic or pyoid corpuscles .... 
37.* Granular corpuscles from cerebral softening 
38.* Cancer-cells from the uterus .... 
39.* Structure of central portion of a tubercular mass from the brain 
40.* Structure of external portion of same mass 
41.* Fragments of phosphate of lime, crystals of cholesterin, and tubercle corpuscles 

from a cretaceous mass in the lung 
42.* Section of gray granulation in the lung, after the addition of acetic acid 
43.* Tubercle corpuscles mixed with pigmentary matter 
44.* Scrofulous matter from subcutaneous deposit 
45.* Scrofulous pus .... 

46.* Scrofulous pus from lymphatic gland 
47.* Pus from a scrofulous abscess 

48. Drawing of a fibrous tumor 

49. Fibro-fatty tumor . ... 

50.* Fat cells and granular cells from a steatomatous tumor of the ovary 
51.* Structure of a fatty tumor from the back 

52. Fibro-cystic tumor from the back 

53. Epithelial growth and tumor . . 

54. Melanic deposit in cells of an engorged lung 

55. Adipose tissue from a fatty tumor 

56. Enchondroma, microscopic structure . 



xu 



LIST OF ILLUSTKATIONS. 



FIG. 

57. 
58. 

59. 
60. 
61. 
62. 

63. 

64. 
65. 
66. 

67. 

68. 

69/ 

70/ 

71/ 

72. 

73. 

74, 

75, 

76, 

77 

78 

70 

80 

SI 

82 



84. 

85. 

86. 

87. 

88. 

89. 

90. 

91. 

92. 

93. 

94. 

95. 

96. 

97. 

98. 

99. 
100. 
101. 
102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
110. 
111. 
112. 
113. 
114. 
115. 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 



I Microscopic appearance of the vessels in meningitis 

Deposit of tubercular matter in the Sylvian fissure of the brain 

A hydrocephalic skull of a girl aged 11 years 

Tumors at the choroid plexus mistaken at first for tubercles 

Portion of choroid plexus, exhibiting a fatty degeneration of the epithelium 

Apoplectic effusion in the brain .... 

Hemorrhage into the ventricle and substance of the brain . 

Vessels from a brain affected with red softening . 

Cancerous tumor from the brain .... 



* Section of the circumference of an enchondroma from the pelvis 

* Corpuscles from softened part of the same tumor . 

* The same after the addition of acetic acid . 
Example of ossification of enchondromatous tumor 

Osseous tumor of os innominatum 

Simple serous cyst and epithelial particles from its interior . 
Diagram of compound cysts . . . . 

Pancreatoid sarcomatous tumor .... 

Structural elements of same ..... 
Various forms of encephaloid cells . . 

* Simple and compound cancer-cells .... 

* Cells from encephaloid of tongue .... 

,:, [ Cancer-cells before and after the addition of acetic acid; also, the structure of 
,|, j the reticulatum from encephaloma of the testicle 

",;, > Young cancer-cells, before and after the addition of acetic acid 

.* Fungus hasmatodes ...... 

.* Cells loaded with black pigment from a melanotic tumor of the cheek 

. Fibroid stroma of a scirrhous tumor of pylorus 

. Scirrhous tumor of cerebrum ..... 

.* Section of a carcinomatous tumor of the breast 

.* Another portion of the same treated with acetic acid 

.* Cancer-cells from the cream-like juice squeezed from the tumor 

,* The same with the addition of acetic acid . 

.* Dense fibrous and elastic tissue, in which cancer-cells are infiltrated, from the rectum 

.* Cancer-cells scraped from the surface in the same case 

.* The same after the addition of acetic acid 

. Colloid cancer of a lymphatic gland . 

.* Form and structure of the same 

.* Epithelial cancer 

.* Cancerous tumor of the cheek . 

,* Epithelial cancer 

. :;: " Free cancer nuclei 

,* Forms of cancer-cells from the polygonal or type variety 

.* Caudated cancer-cells 

.* Fusiform cancer-cells 

.* Fusiform corpuscles of fibro-plastic tissue 

.* Concentric cancer-cells 

.* Compound cancer-cells 

.* Agglomerated nuclei 

,* Pus-corpuscles 

.* The same after the application of acetic acid 

,* Young epithelial scales 

.* Tessellated epithelium 

,* Buccal epithelial scales 

.* Spherical fibro-plastic cells . 

.* Cartilage elements from condyles of femur 

.* Costal cartilage 

.* Corpuscles of tubercle 

.* Cylindrical and ciliated epithelial elements 

. Drawing of mycoderm of favus 

. Taenia solium; head and joints 

. Taenia lata .... 

. Echinococcus .... 

. Bone-like substance attached to falx cerebri 

. Subarachnoid effusion 

. Hemorrhagic effusion in the brain 

. Purulent effusion beneath the arachnoid 

. Meningeal vessels invested and surrounded by exudation-matter 



LIST OF ILLUSTRATIONS. 



XUl 



FIG. 

128. Portion of the spinal cord of a patient who died paraplegic 

129. Part of the spinal cord from a case of paraplegia with angular curvature of the spine 

130. Atrophy of optic nerves .... 

131 ) 

l ^9* r Neuromata of stump after amputation 

133.* Section of a neuroma .... 

134.* Fibrous structure of neuroma 

135. Tumor implicating the posterior tibial nerve 

136. Ordinary form of neuroma .... 
137.* Tumor implicating a median nerve . 

138. A heart covered with plastic exudations 

139. Specimens of fatty degeneration of the heart 

140. Aneurism of left ventricle of heart 

141. Fibroid thickening of mitral valve 

142. Fibroid thickening of a pulmonary valve 

143. Aortic valves of a child, opaque, thickened, and adherent 

144. Atheromatous deposit in valves of aorta 

145. Calcareous deposit in aortic valves 

146. Ossification of aortic valves .... 

147. Aneurism of mitral valve .... 
148.* Plastic deposits in aorta .... 
149.* Plastic plugs occluding axillary artery 
150.* Incipient atheroma and fatty degeneration of an iliac 
151.* Fatty deposits in internal coat of an artery 
152.* Early stage of atheroma .... 
153.* Atheroma from old patch .... 
154.* Steatomatous degeneration .... 
155,* Fatty granules, with crystals of cholesterin,from atheromatous deposits in the aorta 
156.* Calcareous deposition in coats of an artery . 
157.* Annular calcification of the coats of an artery 
158. Aneurism of the arch of aorta 
159.* Aneurism of the brachial artery 
160. Aneurism of posterior tibial artery 
161.* Growth of aneurism arrested by coagulum . 

162.* Spontaneous cure of aneurism by the sac being filled with coagulum 
163* 
164.* _ 
165.* Aneurism of aorta which induced caries of the vertebrae, and fatal compression of 

the spinal cord 
166* 
167.* . 

168.* Varicose aneurism 
169.* Fibrinous phlebitis 
170. Section of liver, exhibiting the appearances presented in inflammation of vena portse 
171.* Varix of veins of leg ....... 

172. Calcareous deposit in the coats of a vein . . . 

173. Acute ulceration of epiglottis ....... 

174. ■) 
175.* > (Edema of the epiglottis .... . 

176.* J 

177.* Ulceration of the larynx ....... 

178. Enlargement of follicles of mucous membrane of the trachea 

179.* Example of false membrane in croup ..... 

180. Injection and stasis of vessels of bronchial mucous membrane in bronchitis 

181. Dilated bronchi . . . . ... 

182. Cretaceous enlargement of a bronchial gland .... 

183. Portion of emphysematous lung ...... 

184. Pulmonary apoplexy ........ 

185. Red hepatization of lung ....... 

186. Microscopic characters of the contents of an air-vesicle in gray hepatization 

187. Pleural surface of a portion of splenified lung .... 

188. Miliary tubercle of pulmonary tissue . . ... 

189. Microscopic appearance of miliary tubercle ..... 

190. Miliary tubercle in close aggregation, recently deposited — magnified 60 diameters — 

and studded with carbonaceous matter 

191. Hexagonal appearance caused by the mutual pressure of the air-cells filled with 

yellow tubercular matter 

192. Microscopic appearance of minute vessels surrounding air-vesicles in tubercular 

pneumonia ........ 

193. Section of an air-vesicle filled with yellow tubercle and surrounded by exudation 

corpuscles ......... 



Front and back view of aneurism of the arch of aorta which burst into trachea 



Front and back view of aneurism of aorta producing absorption of ribs . 



XIV 



LIST OF ILLUSTRATIONS. 



PAGE 

425 
426 
426 
429 

431 

435 
435 
436 
443 

444 

452 
456 
457 
459 
460 
462 



194. Apex of lung affected with tubercular pneumonia ..... 

195. Lung with extensive tubercular disorganization ..... 

196. Apex of lung containing numerous cavities with tubercular deposit intervening 

197. Cicatrix at the apex of lung, resulting from the previous arrest of tubercular disease 

tV? > Infiltrated cancer of lung, with its microscopic elements .... 

200. Straw-colored lymph, coating the lower lobe of an inflamed lung, in recent pleurisy 

201. Portion of lower lobe of left lung compressed by turgid serum occupying the pleural cavity 

202. Lymph of pleuritis with new vessels already formed in it 

203. Old cartilagiuoid capsule of apex of lung 

«,.,,' > Naked-eye and microscopic view of cancer of pleura 

206.* Tongue swollen by glossitis ..... 

207. Tooth attached by caries, with barrier of secondary dentine 

208. Imperfect formation of enamel .... 
209.* Purulent cyst at the fang of a decayed tooth 
210.* Stricture of the oesophagus ..... 

211. Portion of inflamed peritoneum with numerous glomeruli between the fibres 

212. Vertical section of mucous membrane of stomach, the tubes completely wasted and 

replaced by fibroid tissue ........ 

213. Vertical section of mucous membrane of stomach, showing the lower parts of the 

tubes, and a nuclear mass extending among them upwards 

214. Cavity formed in the mucous membrane of stomach by the disintegration of a nu- 

clear mass ......... 

215. Perforating ulcer of stomach . . . . . 

216.* Scirrhus pylori ......... 

217.* Strangulation of intestine by mesentery or omentum .... 

218. Diagram of intussusception ........ 

219 * ) 

noQ*$ \ Prolapsus ani ...... 

221. Vertical section of Peyerian patch and solitary gland of large intestine 

222. Typhous ulcers in small intestines ....... 

223. Inflamed mesenteric gland in typhus, and so-called typhous matter 

224. Typhous ulcers in various stages ....... 

225.* Piles after excision, showing the dilated veins of which they are in a great mea- 
sure composed ......... 

226. A slightly lobulated tumor, passed per anum, divided in its middle and cut edges exposed 

227. Section of liver, showing nutmeg appearance ..... 

^g" } Fatty degeneration of liver ....... 508-513 

230. Fibres originating from fibrous tissue of a cirrhotic liver .... 514 

231. Section of liver in advanced state of fatty degeneration . . . .515 

232. Hepatic cells filled with oil, and from which the oil has escaped . . . 516 

233. Encephaloid growth in liver ........ 523 

234. Gall-stones .......... 529 

235. Cholesterin and glomeruli from gall-bladder ...... 530 

236. Gall-bladder and cystic-duct containing calculi ..... 530 
237.* Salivary calculus ......... 532 

238. Fibroid thickening of capsule of spleen ...... 537 

239. Masses of crude tubercle in spleen ....... 538 

240. Cyst in the capsule of spleen ........ 538 

241.* Bronchocele .......... 539 

242.* Section of bronchocele, showing calcareous deposits .... 539 

243. Hemorrhage into Malpighian capsules ...... 544 

244. Tube from kidney containing yellow granules, the remains of extravasated blood 544 

245. Fibrinous deposits in a granular kidney ...... 547 

246. Red deposit from urine in intense renal hypersemia ..... 543 
rt.*. ( Renal tube containing an homogeneous cast ... . . . 549 

' { Malpighian body, the capsule filled with oily matter .... 549 

243. Diseased cortical tubes of liver ....... 550 

249. Diseased cortical and medullary tubes ...... 550 

250.* Diseased tubuli uriniferi . . . . . . . .551 

251. Atrophied kidney ......... 553 

252. Cortical portion of granular kidney ....... 553 

253. Thickened condition of matrix of kidney ...... 554 

254. Renal cysts and cyst-like casts ....... 55 

255. Kidney converted into cysts ....... 562 

250. Pyelitis ••-......! 562 

257.* Extrophy of bladder ........ 564 

258.* Sacculation or partial dilatations of bladder . . . . .565 

259. ;: Hypertrophy of muscular coat of bladder ...... 566 



463 

469 

469 
472 

477 
482 
484 

485-486 

489 
492 
493 
493 

502 
503 

508 



LIST OF ILLUSTRATIONS. 



fig. 

260. 1 

261 * ' 

2fi2* <* Strictured urethra 

2m'.* j 

264. Urinary deposits 
265.*' 

266* 

267.* 

268.* 

269.* 

270.* 

271.* * 

272* 

273.* 

274.* 

275.* 

276.* 

277.* ; 

,L' # [ Earthy phosphates 

280.' 

281.*] 

282* 



Uric acid crystals 



XV 

PAGE 

571-572 
576 



577-576 



284. 
285, 
286 
287 
288 
289 
290 
291, 
292, 
293, 
294, 
295, 
296. 
297, 
298. 
299, 
300. 
301, 
302, 
303. 
304 
305. 
306. 
307. 
308. 
309, 
310. 
311. 
312. 
313, 
314. 
315. 
316. 
317. 
318. 
319. 
320. 
321. 
322 
323, 
324 
325 
326 
327 
328 
329 
330 
331 



Oxalate of lime 



Dumb-bell crystals 
Cystine 



.# Lithic calculus 

,* Section of lithic calculus showing internal structure 

,* Oxalic or mulberry calculus 

* Internal structure of same . 

* Cystic calculus .... 

* Internal structure of same . 

* Phosphatic calculus .... 

* Ammonia magnesian calculus 

* Fusible calculus .... 

* Internal structure of same . 
, Inflammation of tunica vaginalis 
, Hydrocele combined with scrotal hernia 
, Encysted hydrocele of tunica vaginalis 
. Haematocele ..... 
,* Bruise of scrotum, a form of haematocele 

* Acute orchitis .... 
, Chronic orchitis, with fungous protrusion of testis 
. Section of cystic sarcoma of testis 
, Contents of various cysts in the same 
,* Hypertrophy or elephantiasis of scrotum 
,* Chimney-sweepers' cancer . 
.* Corpuscles from the same 

'^ I Enlarged prostate 

* Lobulated hypertrophy of prostate 

* \ 
' i Hypertrophy of middle lobe of prostate 

* Irregular hypertrophy of middle lobe 

* Abscess of prostate . 

* Cyst of prostate 

* 1 
[ Prostatic calculi 

* Chancre of prepuce . 
.* Phymosis 

* Paraphymosis 
.* Warts on penis 

. Fibrous tumor projecting in the cavity of uterus 
. Fibrous tumors of walls of uterus 
. Atrophied placenta 
, Incipient cyst-formation in ovary 
. Multilocular ovarian cyst 



579 



5S0 



580 



581 

5S1 
5S1 
582 
5S2 
582 
582 
583 
583 
5S3 
583 
587 
5S8 
589 
590 
591 
592 
593 
595 
596 
597 
598 
59S 

599 

600 

600 

601 
602 
603 

603-604 

605 
606 
606 
608 
619 
620 
636 
647 
648 



XVI 



LIST OF ILLUSTRATIONS. 



PAGE 

652 
653 
653 
654 



332.* Sero-cystic tumor of mamma ....... 

333.* Cysto-sarcoma of mamma ......... 

334.* Cysto-sarcoma from neighborhood of mamma ..... 

335. Lobular hypertrophy of mamma . . . 

336.* ) 

337.* [-Microscopic sections of simple tumor of mamma ..... 

338* J 

339.* Carcinoma of mamma bisected ....... 

340.* Secondary carcinoma ........ 

341. Cancerous tumor of mamma ........ 

342. Secondary deposit in knee-joint ....... 

343. Diseased cartilage ......... 

344.* Fibriated knee-joint ........ 

345.* Trochlea of humerus, showing formation and connection of loose cartilaginous bodies 

346. Cartilage of patella in state of usure ....... 668 

347.*] 

349 * r Diseased articular cartilage ...... 668-669 

350>J 

351.* Deposition of calcareous matter, commencing in the walls of the cartilage-corpuscles 

352. Ulceration of cartilage . 

353.* Destruction of cartilage in knee-joint 

355 * l Spinal curvature .... 

356.* Enlarged bursa over patella ... 

357.* Microscopic drawing of inflamed and softened bone 

358.* Suppuration in bone 

359.*" 

360* 

361* 

362* 

363.*] 

364 * 

"# [ Caries in bone 



Abscess in bone 



365 

366* 

367* 

368* 

369* 

370* 

371." 



'# j- Necrosis of head of femur, acetabulum, and shaft 

373.'^ 

374.^ 

375^ 

376/ i 

377. Section of the femur of a rickety child cut with a knife 

378.*" 

379* 

380* 

381* 

382* 

383* 

384* 

385* 



Rickets affecting the femur, tibia, and humerus . 

Permanent curvature of the spine, with rotation, produced by rickets 

Example of limbs deformed by rickets 

.h. * (■ Front and back view of lateral curvature of spine 

388. Enchondroma .... 

389.* Ivory exostoses of os frontis 

390. Spongy exostosis on the femur 

391.* Exostosis of femur 

392. Osteophytes occupying lower end of femur 

393.* Osteocephaloma of head of humerus 

394.* Section of the same tumor 

395.* Osteocystoma of lower end of femur 

396. Section of femur affected with mollities ossium 

397. Bone-corpuscles .... 



654 

656 
656 
656 
661 
664 
665 
666 



670 
670 
673 

674 

680 
685 
687 



687 



689 



690-695 



695 
696 

698 
699 

701 

705 

706 
707 
707 
708 
713 
713 
718 
720 
722 



MANUAL 



OF 



PATHOLOGICAL ANATOMY, 



CHAPTER I. 

GENERAL OBSERVATIONS. 

The object of General Pathology is to examine the various morbid 
processes which may occur in the human body, and to obtain, thereby, 
such an insight into their nature, that they may not be looked on as 
unknown entities, but that being comprehended as far as is possible 
themselves, the various effects they produce, the particular instances of 
their action, may be understood also. 

The course we propose to follow is nearly that which Dr. Williams 
has adopted so successfully, in his work on The Principles of Medicine. 
We shall, therefore, describe, briefly : (I.) The morbid alterations of 
the several great functions. (II.) Those of the blood. (III.) Those 
of the various tissues, considered generally. (IV.) The superadded 
formations or growths, the so-called tumors. (Y.) Parasitic beings, 
whether animal or vegetable. 

Some general observations must, however, be premised. The term 
Morhid Anatomy hardly needs explanation ; as ordinary anatomy im- 
plies the study of, and acquaintance with, the healthy structure, so 
morbid anatomy implies the same of diseased structure. The meaning 
of Pathology may be clearly conceived, by considering that of its twin 
sister, Physiology ; as the latter imports the knowledge of the natural 
actions of healthy organs, so does the former that of the unnatural 
actions of diseased or disturbed organs. Physiology has her vital 
stimuli ; Pathology her stimuli or excitants to unhealthy life. This 
expression brings us to notice a point which has been excellently illus- 
trated by Prof. Simon. He remarks that many unnatural or diseased 
conditions are not really unnatural in themselves, but are the proper 
and necessary consequences of some cause or influence which has acted 
upon a healthy body. The state of skin which a severe burn produces 
is, certainly, very unnatural and diseased, but the inflammatory and 
exudative processes which have produced it are quite natural, under the 
3 



34 GENERAL OBSERVATIONS. 

circumstances that have occurred ; they are the proper reaction of a 
healthy organism to the unnatural stimulus of extreme heat, and are 
called forth in the same way as is the healthy flow of blood into a 
chilled part by the action of kindly warmth. So in a case of variola, 
the skin, covered all over with unsightly pustules, is in a very unnatural 
state ; but it is not the eruption, nor the constitutional disturbance, 
neither, that is really unnatural, but the presence of a certain quantity 
of infectious matter in the blood, which, acting on a perfectly natural 
system, thus calls forth its expulsive efforts. If we slightly alter this 
perfectly natural state, as by premising vaccination, then the introduc- 
tion of the variolous poison no longer produces the same morbid effects, 
and we say the system is protected. The fact is, the system is changed 
from its originally perfectly natural condition, and will no longer 
respond to the unnatural stimulus. We find, it may be, a portion of 
the brain so soft as to resemble cream, quite broken up and disorgan- 
ized ; but, we look further and find that the artery supplying it with 
blood has been plugged up or tied, and we then see that the locus of 
the disease was not really in the brain, but in the artery ; it would 
have been abnormal had the brain, deprived of its supply of blood, re- 
tained its natural texture. Or, again, we see a person suffering from 
violent epileptic convulsions ; but, he passes a large worm from the 
bowels, and the attacks cease: in the case of this individual, the con- 
vulsions were the natural expression of the unnatural irritation to 
which the brain was subjected. Many like instances might be men- 
tioned, and they certainly show that disease is, very often, not to be 
regarded as a special entity of a peculiar, strange kind, but as the 
natural result of the endowments and qualities belonging to our bodily 
organs, when those organs are acted on by certain unnatural stimuli. 
Hence, we can better understand that many diseases have a regular and 
normal course, made up, so to speak, of a succession of necessary 
results, which, however, is liable to be disturbed by various extrinsic 
causes. For instance, a person has ague, the paroxysms occurring in 
regular succession ; he takes quinine, and they diminish and disappear, 
the course of morbid action is interfered with and broken. Or, a child 
has hooping-cough, and the disease is proceeding in its usual course, 
but in consequence of exposure to cold, he is attacked with inflamma- 
tion of the lungs, and the paroxysms characteristic of the disease are, 
to a great degree, interrupted; the hooping-cough is merged in the 
pneumonia. Or, again, a person has tubercular deposit in his lungs; 
the natural tendency of this is to soften, break down, and be expecto- 
rated, together with the involved tissue, while, as fresh deposits take 
place, more and more of the organ is destroyed ; but, before this can 
happen, inflammation is set up to such an extent, in the surrounding 
tissue, that life is cut short, not by the effects of the tubercular de- 
struction directly, but by the intercurrent inflammation. 

The unnatural stimuli, provoking the succession of morbid actions, 
are often termed the Exciting causes of a disease ; they may be ade- 
quate, when powerful of themselves, to produce their effect, or, may 
need the assistance of other causes, generally of a debilitating nature, 
which are called Predisposing. 



GENERAL OBSERVATIONS. 35 

But the question now occurs, whether all diseases are of the kind 
above mentioned, whether all can be regarded as the natural results of 
certain foreign injurious influences operating on the system. To this 
the answer, in the present state of pathology, must be, I think, cer- 
tainly not. There are very many cases where we cannot point out any 
exciting cause of the existing malady, where it seems to have originated 
spontaneously, so far as we are able to judge. Of this kind are many 
instances of decay and degeneration of tissues, very many of mal- 
assimilation, or mal-secretion, hereditary diseases, and some congenital 
mal-formations. It may be that, as we advance in knowledge, we shall 
be able to include more and more of the latter class under the former ; 
that as we obtain more acquaintance with the imponderable influences 
which are constantly in operation, we shall be able to refer to them as 
the causes of changes which now appear spontaneous, but from this we 
are far, at present, and must thoroughly recognize the two classes of 
disease which we have just described. These classes, however, are not 
(and natural groups never are) rigorously defined; there are numerous 
instances of an intermediate kind, such as those where a slight exciting 
cause calls into action an inherited predisposition. We must also no- 
tice another great division of diseases into two classes, viz: the Organic 
and Functional. Of the existence of the latter many of the best 
pathologists greatly doubt, that is to say, whether it be possible for the' 
mechanism of an organ to be perfectly uninjured, at the time that its 
function is wrongly performed. Speaking in the strictest sense, and 
remembering the advances which have been made in detecting morbid 
alterations formerly unknown, as well as the amount of progress which 
we may yet look to make, it must certainly be allowed that it is quite 
possible that the division above mentioned is not founded in reality, and 
that all diseases are attended with organic change. But, when this is 
conceded, it remains still perfectly clear that there are not a few 
diseases, and some very severe, in which no organic alteration whatever 
can be detected; and it seems, further, a point of considerable practical 
importance that the student should be fully aware of this and alive to 
it. For the functional disease often nearly simulates the organic, or 
may succeed it, or exaggerate it, and the practitioner who is not care- 
fully on the watch for the possible occurrence is very apt to be led 
astray. How often has dyspnoea, depending on disordered innervation, 
been treated as pneumonia, palpitation of similar origin considered as 
tbe result of serious cardiac disease, venesection been employed to 
relieve nervous headache, and so on ! In this time of generally defi- 
cient power, and sensitive nervous systems, it behoves us especially to 
be on our guard against mistaking a functional for an organic disease. 
As in the preceding case, so in this, the two divisions which we recog- 
nize of diseases are not rigorously defined, they have each their marked 
exemplars, between which the intervening space is filled up with every 
possible grade. Functional disease may produce organic, either of the 
organ which itself affects, or of some other. Thus, epilepsy long con- 
tinuing, produces morbid alteration of the cerebral structure ; dyspepsia 
may be the cause of some unsightly cutaneous eruption. Organic dis- 
eases are much more often latent than functional. A man may have 



36 GENEEAL OBSERVATIONS. 

serious heart disease, and think nothing about it, but he will be greatly 
alarmed if he suffers from an irritable palpitating organ. This fact, 
and the oft-repeated observation that post-mortem examination discovers 
no sufficient cause of death, testify, as well as the instances in which 
functional disease is itself fatal, to the reality and importance of func- 
tional disorder, either independent of, or out of all proportion to, or- 
ganic alteration ; and warn us that, necessary and philosophic as it is 
to investigate to the utmost the morbid changes of solids or fluids, and 
to endeavor to arrive by this way at a knowledge of the essential 
causes, and at sound indications of treatment, we must never overlook 
those grand plain intimations which nature gives of functional vigor or 
debility. Such considerations as these may be foreign to morbid 
anatomy; they are not inappropriate to pathology. What are called 
idiosyncrasies are unusual peculiarities of an individual system, in 
consequence of which it is affected in a different manner by some in- 
fluences to that which is commonly experienced. Thus, some persons 
are attacked by asthma or bronchitis on inhaling the odor of hay ; 
some are almost poisoned by taking the smallest dose of a mercurial. 
One at least has been mentioned (by Dr. Prout) who could not eat 
mutton in any form without being attacked by violent vomiting and 
diarrhoea. In such persons the qualities and endowments of one or 
more organs must be essentially different to those of the same parts in 
the vast majority of mankind. Yet there is not the least reason for 
supposing that, by any scrutiny, we could detect any structural differ- 
ence, and they must, therefore, be deemed instances of aberring func- 
tion. 

One remarkable instance it seems worth while to adduce here, which 
affords an excellent illustration of the connection that may obtain be- 
tween disordered function and alteration of structure. The Graafian 
vesicle in the ovary, instinct with a wonderful capacity of life, which 
only needs its appropriate stimulus to rouse it into that activity which 
issues in the production of another being, not unfrequently, as if affected 
by some strange and unnatural stimulus, proceeds to develop itself into 
a huge anomalous growth, utterly imperfect, and unlike what, under 
normal conditions, it should have produced, and yet exhibiting some 
traces such as are found in no other growth of its original destiny, by 
the formation of several of the natural tissues, skin, teeth, hair, nay, 
even brain, &c. Here, it seems impossible to recognize any other cause 
of the organic alteration beside the perversion or aberrance of a natural 
function or endowment. The term Diathesis is applied to a certain 
condition of the general system often inherited, which renders it espe- 
cially liable to some particular form of disease ; thus, we speak of the 
scrofulous or tubercular diathesis, of the gouty diathesis, and so on. 
If the diathesis or predisposition be strong, a slight exciting cause will 
be sufficient to induce the malady ; if it be absent, no exciting cause 
may produce any effect. A diathesis may, therefore, be considered as 
a kind of special weakness. Degeneration of a part or tissue implies 
generally its slow and gradual conversion into some lower kind of 
structure less fitted for the purpose it has to fulfil, as when cartilage is 
converted into a kind of fibrous tissue ; or it may imply the atrophy 



GENERAL OBSERVATIONS. 37 

and destruction of a part, as of the cortical structure of the kidney in 
Bright's disease. It is to be regarded in some measure as a local in- 
firmity. — As in part a corollary and conclusion to the above remarks, 
I would subjoin the following great practical truth which daily experi- 
ence presses on our attention, viz : that on the one hand there is a 
sound and healthy systemic life, of which all the organs are or ought 
to be possessed, and that, on the other hand, there often comes in its 
stead, either generally or locally, an unsound and unhealthy life, which 
leads to perverted morbid action, or to actual decay. The one is the 
" vis reparatrix," or " conservatrix Nature," withstanding and repelling 
morbid influences, sending a tide of life and vigor through the frame, 
striving to compensate for a casual loss or damage inflicted, and only 
sinking at last in the tranquil decline of a green old age. The other 
is that deathward taint, infecting and debilitating the even youthful 
system, opening wide the avenues to every casual morbid influence, in- 
creasing the power of every disease, and decreasing the capacity of 
resistance to it ; and in fine, either embittering the years of a lingering 
existence, or cutting the span of life prematurely short. Well does 
the physician know and recognize in his patient the two states, different 
as the varieties of the latter may be. In the former, he confidently 
anticipates a successful result ; in the latter, he prepares himself for a 
doubtful, difficult, perhaps only defensive warfare. 

It was formerly a much debated question, whether diseases had their 
principal seat in the fluids or solids of the body ; and each of the two 
opposed theories has at times been dominant. At the present day, we 
marvel how men could have adopted exclusively one view or the other, 
and refused to allow to each their share in the production of morbid 
phenomena. There can be no question, from known physical laws, that 
the blood must, in very many cases, be the first recipient of aeriform 
noxious matters, of all such miasmata as those of typhus, scarlatina, 
&c. The instant that these are drawn with the air into the lungs, they 
pass into the blood ; for it is impossible that the gases contained in the 
blood shall not, according to the law of heterogeneous attraction, be 
exchanged in part for those which are diffused in the air-cells and cavi- 
ties of the lungs. As little doubt can there be that the blood, as it is 
the first to receive, so it is also the first to be modified and altered 
from its healthy composition by the inhaled miasm. In the great class 
of inflammations, the affection of the tissue and of the blood must pro- 
ceed 'pari passu : so intimately is the blood concerned in every stage of 
the process, that it may almost be said both blood and tissue are alike 
the seat of the disease ; but the latter manifestly has the initiative. 
Rheumatic and gouty inflammations must, however, be excepted, in 
which the blood is certainly the primary seat of morbid alteration. 
Scrofulous disease, in all probability, commences in the blood, and pro- 
duces in it a change, of the nature of which we are ignorant, but 
which issues in the deposit of a peculiar matter in various localities. 
In diseases arising from excess in eating and drinking, or from un- 
wholesome aliment, the blood in some cases, and the alimentary canal 
in others, may be primarily affected. When we consider what the 
processes of nutrition and secretion imply, how the blood is a vast 



38 FUNCTIONAL DERANGEMENT. 

laboratory, in which some secretions are actually prepared, and the 
materials of others ; how it conveys to each part the nutriment that is 
appropriate to it, and receives back in return principles more or less 
effete ; how continually it is receiving supplies of new matter from 
without, and undergoing depuration by various appointed emunctories ; 
in short, if we consider how thoroughly the different solid and fluid 
parts of the frame are correlated, and mutually dependent, we shall 
perceive most clearly that it is far more important to be fully aware of 
the extreme liability, nay, necessity, of the solids to be affected by the 
fluids, and the fluids by the solids, and that thus the disorder of one 
part may be the exponent of the error of another, than to attempt an 
almost impossible definition of the exact origin and site of a disease. 



FUNCTIONAL DERANGEMENT. 

We now proceed to consider the morbid alterations which are observed 
in some of the great functions or endowments belonging to some of the 
most important tissues of the animal frame. These have been termed 
by Dr. Williams Primary Elements of Disease; and it seems especially 
desirable to obtain as exact an acquaintance with them as is possible, 
because in these instances morbid action presents itself in its simplest 
and least complicated form. In almost all diseases two or more of these 
are variously combined, and success in treatment depends very much 
on the due appreciation of the several existing elements in each case, 
and of the degree in which one or other predominates. In a common 
case of irritative dyspepsia, for instance, the sensibility of the nerves, 
the tonicity of the vessels, and the secreting action of the follicles, are 
all variously affected, and all react upon and aggravate each other. 
The judicious practitioner will bear in mind the existence of all, and 
will endeavor to apportion his remedies according to the predominance 
of one or other. 

We shall mention first disordered states of Contractility, including 
under this head the modification of it termed Tonicity. This is the 
property of muscular fibre, both of the striped and unstriped varieties, 
though it is manifested differently in them. The contraction of the 
former immediately takes place on the application of a stimulus, and 
soon subsides ; that of the latter comes on more gradually, and is of 
longer endurance. It has been supposed by some that the power or 
quality was not resident in the contractile tissue, but in the spinal cord, 
from which it was conveyed by the nerves to the muscles ; but this view 
seems quite contradicted by observation and by analogy. It is, however, 
perfectly true that contractility is almost always called into play by 
the instrumentality of the nervous system, and that most of its apparent 
disorders have really their seat in the nervous system. Still, we believe 
that there are disordered conditions of contractility itself, though these 
may sometimes have been originally produced by disordered innervation. 
The principal one of these is a condition which may be termed unnatural 
mobility. The tissue is so irritable that it is thrown into action on the 
least stimulus, or even seems almost to contract without a stimulus. 



FUNCTIONAL DERANGEMENT. 39 

At the same time the contraction is often feeble and imperfect, hurried 
and irregular. It reminds one forcibly of the mental condition of an 
anxious, restless, incapable person. This unnatural mobility is often 
observed in the hearts of anemic patients, sometimes in those of persons 
who have undergone severe exertion without proper previous training. 
It is also exemplified in the irritable bladder, which will not contain the 
least quantity of urine, in that state of the intestinal canal which gives 
rise to what is called lientery, and in some conditions of the stomach, 
where every particle of food or liquid that is taken is immediately re- 
jected. It seems doubtful whether contractility is ever so exaggerated 
as to amount to a morbid state, that is to say, contractility regarded in 
its power of action, not merely in its readiness of being excited. We 
might have feared that when muscles became enlarged, and their vigor 
increased by frequent exercise, the osseous levers which they move, 
and which give them attachment, might have proved inadequate to re- 
sist the increased strain; but experience shows us the beautiful adapta- 
tion which provides that, as the . muscle hypertrophies and its force 
increases, the bone also enlarges and strengthens in an equal ratio. It 
may be that in some cases of spasm or cramp the contractility itself 
of the part is excessive, and that it is not only the nervous system that 
is at fault. 

Instances on the other hand are numerous, in which contractility is 
defective. The weakness which we feel on first leaving a sick bed, when 
we can scarcely raise our limbs, depends on defective contractility of 
the muscles, occasioned by long disuse. The same may be the result 
of paralysis, of rheumatic inflammation, of the poisonous action of lead, 
of tobacco, sulphuretted hydrogen, &c. Impaired contractility is a very 
frequent cause of habitual constipation, which may then be best treated, 
as in a case recently under our care, by tonics. The failure of repeated 
purgatives in this instance also exemplifies the truth, that, after violent 
excitement, contractility loses still more its energy, and is still more 
difficult to be called forth. The failure of contractile power in many 
cases, but certainly not in all, is connected with an actual change in 
the structure of the fibre. Of course, if this has degenerated, it cannot 
discharge its function properly, but in other cases the failure of the 
function probably precedes the degeneration. 

Tonicity is observed in the striped muscular fibre, as well as in all 
the varieties of the organic; it is what Mr. Bowman has denominated 
Passive, in opposition to Active contractility ; the latter being the re- 
sponse of a fibre to a stimulus, the former a constant state of tension, 
or approximation of all the points of the fibre throughout its length. 
There is no real difference between tonicity and passive contractility, 
yet it may be stated that the former designation is most applicable to 
the contractility which is manifested by the coats of the bloodvessels, 
and the skin. Heat and cold are the influences which have most effect 
upon tonicity, the former producing marked relaxation, the latter con- 
traction of the tissues which possess it. The possession of this property, 
by the bloodvessels, is of the very greatest importance ; it is intimately 
concerned in many morbid phenomena, and notably in those of inflam- 
mation. When we place our finger on a small, hard, wiry-feeling pulse, 



40 FUNCTIONAL DERANGEMENT. 

such as exists in the. outset of peritonitis, and other membranous inflam- 
mations, we recognize a condition of the artery in which its coats are 
tensely contracted on the stream of blood passing through it, and form 
such a firm cylinder as not to yield to the pressure of the finger. Here 
tonicity is in excess. The rigid state of the walls of the arteries prevents 
their yielding to the distensive force of the wave of blood thrown in by 
each contraction of the heart, and hence there is not the usual interval 
between the impulse at the chest and the pulse in the limbs. In persons 
of a sanguine temperament, tonicity is probably in every part somewhat 
excessive, the muscles are more rigid, and the pulse more firm, than is 
consistent with the most perfect health ; while in persons of a lymphatic 
temperament the same quality is deficient in a corresponding degree. 
When tonicity is naturally somewhat excessive, a cold, dry atmosphere, 
or an easterly wind, may cause considerable discomfort and disturbance 
of the system. The superficial vessels and the integuments are so con- 
stringed, that the blood is repelled inwards in undue quantity, and the 
exhaling function of the skin materially interfered with. On the con- 
trary, where tonicity is naturally defective, the very same influences 
may be of decided benefit. A case has come within the knowledge of 
the writer, in which the tonicity of the cerebral vessels became greatly 
impaired in consequence of enfeebled health, and much mental strain. 
To such an extent had this proceeded, that sleep was very much dis- 
turbed, and rest prevented; as immediately on lying down blood was 
transmitted in undue quantity to the brain, unrestrained by the toneless 
vessels, which were felt pulsating violently. The relief experienced in 
this case on the setting in of cold weather was most marked, and was 
clearly produced by the diminished temperature having aroused the 
tonicity of the weakened vessels. That distressing affection which not 
remotely simulates aneurism, an atonic condition of the abdominal aorta, 
is another instance of the same kind. It is clear that an atonic state 
of the vessels must predispose extremely to local congestions, which 
may often advance to asthenic inflammations; it must also be a frequent 
cause of a varicose state of the veins. In those alarming, but happily 
rare cases, where the slightest wound occasions considerable hemorrhage, 
which can scarcely be restrained, it seems most probable that the tonicity 
of the vessels is chiefly in fault, that they do not contract as they should 
when cut across, and thus close the bleeding orifices. The effect of cold 
in restraining hemorrhage, and of heat in promoting it, is matter of 
common observation, and is of course produced by their action on the 
coats of the vessels. The state of the pulse is an excellent indication 
of defective, as it is of increased tonicity ; the soft, yielding, large vessel 
has evidently its coats in a state of relaxation, and the wave of blood in 
it is not felt till some space after the impulse at the chest. Nervous 
influence is evidently capable of arousing or depressing tonicity; but it 
is equally clear that the quality itself exists in very various degrees. 
The loss of tonicity in the vessels leading to an inflamed part, we shall 
hereafter see to be an important circumstance in the process of inflam- 
mation. 

From the examination of that great system which is the seat of con- 
tractile power, we proceed to that which is the seat of nervous power ; 



FUNCTIONAL DEKANGEMENT. 41 

and we shall first consider its disorders with regard to its faculty of 
receiving impressions and converting them into sensations. This power 
is termed Sensibility ; it may be morbidly increased, or diminished, or 
perverted ; and these alterations may be either general or local. When 
sensibility is generally excessive, the indications of it are so plain, that 
it is almost needless to enumerate them. The sufferer may be com- 
pared to a sensitive plant — shrinking from every touch. Every pain 
or ache seems prodigiously magnified in intensity, and is described in 
hyperbolic language. The important points to bear in mind in dealing 
with such cases are : (1), that real disease may coexist with this hyper- 
sensitiveness, and that we must not, therefore, too hastily ascribe all 
" to the nerves;" and (2), that if such real disease do exist, some of its 
symptoms will probably be greatly intensified to the patient's sensations, 
so that we might easily be led to think the disease more serious than it 
really is. The condition now mentioned is essentially chronic ; and is 
to be distinguished from that state which exists in cases of inflamma- 
tion of the brain, or determination of blood thither, or an irritation of 
the organ from any cause. In these there is also intolerance of light 
and sound, and any jar or movement is painful. This condition, how- 
ever, is never of long continuance, and is often succeeded by an opposite 
state, and is evidently dependent upon inflammatory excitement. De- 
lirium tremens is not properly an instance of increased general sensi- 
bility, as it does not appear that the nerves are concerned in exciting 
the disorder of the sensorium. It seems, however, so far to belong to 
the morbid state we are now considering, in that it consists, certainly 
to a great degree, of an unduly excited state of the sensorial centre, the 
excitement, however, being dependent rather on immaterial than on 
physical impressions. The known exciting causes of delirium tremens 
are also just those which are likely to produce excessive sensibility; they 
are such as irritate and excite the nervous system for a length of time, 
succeeded by such as occasion general debility. This affection, there- 
fore, with its occasional tendency towards inflammatory excitement 
which it sometimes presents, seems to hold an intermediate place be- 
tween the common chronic habitual hyperesthesia, and that excessive 
intensity of the function which is seen in phrenitis, &c. Sensibility 
may be increased locally — a part may be so tender as to be almost 
unable to bear the lightest contact. This depends sometimes on an 
inflammatory condition of the part, sometimes on a simply altered state 
of its innervation. The illustrations of the first are of constant occur- 
rence ; those of the second are furnished by the instances of what is 
called irritable breast, testicle, or uterus. The intolerance of light, 
which is so marked a feature of scrofulous ophthalmia, shows a condition 
of the retina which must be regarded as one of hyperesthesia, not 
dependent on inflammatory action. It is very remarkable that the 
internal organs, which, in their healthy life, are devoid of common sen- 
sibility, should, when affected by disease, become so acutely sensitive. 
Who knows aught of what is going on in his stomach, while it is digest- 
ing healthfully ? or how his gall-bladder or intestines or ureters are 
acting on, and transmitting their contents ? But let disease arise in 
these parts, and then their actions become attended with pain, some- 



42 FUNCTIONAL DERANGEMENT. 

times so severe that the like is seldom experienced. We are able, in 
some measure, to account for the fact, by remembering that the sympa- 
thetic nerves, which supply the intestines, &c, contain numerous cerebro- 
spinal fibres, and also that the nerves, in their course, pass through 
numerous ganglia, which probably serve, under ordinary circumstances, 
as centres of nervous influence, beyond which the impressions are not 
conveyed. Diminished sensibility is not unfrequently observed as the 
result of stupor, or coma, in whatever way induced. It is necessarily 
consequent on division of the spinal cord, in all parts supplied with 
nerves below the seat of the lesion ; and it often occurs partially in 
apoplectic or paralytic attacks. In these, however, it is rarely so com- 
plete or so persistent as the loss of motion. The retina not unfre- 
quently loses its sensibility, either for a time or permanently, without 
exhibiting -any trace of disorganization ; and there are analogous 
instances in which deafness, more or less complete, results from paralysis 
of the auditory nerve. The application of cold is a powerful means of 
diminishing sensibility. Of this, we have a familiar instance in the 
numbed condition of the fingers which is so frequent in cold weather. 
In this instance, the nerves lose their sensibility, in consequence of 
their being deprived of their usual supply of blood ; the part is anemic, 
as well as numb ; and this arrest of the circulation again depends on the 
action of cold upon the tonicity of the arteries, which become so con- 
tracted that they no longer transmit a free current of blood. Here we 
have a good illustration of the dependence of the several parts and 
functions one upon another. It is, however, most probable, or almost 
certain, that cold directly tends to diminish sensibility, by its action 
upon the nerves themselves. We have constant opportunities of 
observing how confinement to warm rooms tends to induce a state of 
generally increased sensibility; and how this condition is corrected and 
removed by a free exposure to the inclemencies of the weather. Sensi- 
bility may be perverted in many various ways. Persons suffering under 
cerebral affections, either functional or organic, experience sometimes 
peculiar sensations in different parts of their bodies. These may resemble 
the crawling of insects over the surface (formication), pricking with pins 
and needles, tingling, &c. Pruritus, and all the varieties of itching, 
must generally be referred to a peculiar alteration of sensibility in the 
nerves, distinct from that which is produced in them by common inflam- 
mation. In the severest forms of this affection, no inflammation at all 
is present. It is interesting to observe that itching may be dependent 
simply on a disordered crasis of the blood, or the presence of some 
unnatural element in this fluid. Thus in jaundice this symptom is fre- 
quently observed, and is doubtless occasioned by some biliary constituent 
being absorbed from the liver, and carried along with the blood. Pain 
seems to be properly included also under the head of perverted sensi- 
bility, as it is certainly something more than simply exaltation of this 
endowment. On this ground we may refer to neuralgia, and especially 
to the affection called tic douloureux, as affording the extremest instance 
of perverted and also exalted sensibility. The affected part may be 
sometimes the peripheral; more often, probably, the central. However, 
in neither case does there appear to be any alteration of structure that 



FUNCTIONAL DERANGEMENT. 43 

could account for the disease. 1 This instance, and that of pruritus, are 
especially worthy of notice. They seem to afford us strongly-marked 
examples of extreme disturbance of a single function, without any com- 
plications, and unattended by any discoverable lesion of structure. 
Another circumstance worthy of remark, with respect to altered sensi- 
bility, is that the symptom does not always manifest itself in the part 
which is the seat of irritation, but in some other, at a distance. Thus, 
severe headache is occasioned in some persons by taking some article of 
food which offends the stomach. Pain in the knee is a well-known 
symptom of disease of the hip joint ; and pain at the extremity of the 
penis, of a stone in the bladder. No satisfactory explanation of this 
fact has yet been given ; but it seems most probable that the impres- 
sion transmitted to the centre, there affects, in some unknown way, the 
contiguous extremity of the nerve of the part to which the sensation is 
referred. 

Another function of the nervous system, of its central organ, is that 
of Voluntary motion, and this also is subject to morbid alteration. In 
mania and delirium, the power is sometimes extraordinarily intensified, 
so that a naturally weak person may resist the force of several strong 
men. Great mental energy and powerful emotions also increase the 
power to a great degree. The brain in such conditions may be com- 
pared to a highly charged and constantly acting electric battery. On 
the other hand, debilitating and depressing causes, congestion, narco- 
tism, or stupor, impair the voluntary power, as also sudden alarm, or 
great anxiety. To speak of the paralyzing effect of terror is scarcely^ 
metaphor. Instances of perversion of this faculty are found in various 
strange affections, more or less allied to hysteria, such as the tarantula 
dance, certain religious ecstasies, and the cataleptic state. Partial 
defect of voluntary power is very commonly observed as the result of 
interruption of the transmission of nervous influence to the part. Thus, 
if the dynamic mechanism of the centre be damaged by apoplexy, or 
the texture of the cord be destroyed, or a nerve subjected to atrophic 
pressure, paralysis more or less complete of the part must take place. 
But there are certain cases in which there is no reason to imagine that 
any disease of the nervous system exists, yet affected with more or less 
complete paralysis of some part. To such the term hysterial paralysis 
is applied; the,y are rather diseases of the mind or emotions than of 
any part of the bodily frame. It is very important to be aware of the 
existence of such diseased states, both for the sake of avoiding errors 
in treatment, and also that we may estimate aright the wonderful in- 
fluence which our immaterial is capable of exerting upon our material 
organism. 

That property of the spinal cord and its prolongation upwards within 
the cranium, by virtue of which an impression communicated from an 
internal or external surface occasions a motor impulse to be conveyed 
outwards along corresponding nerves which are distributed to certain 
muscles, is liable to be morbidly affected, and thus to become the cause 

1 Dr. Romberg, however, has given the details of a case in -which the most severe facial 
neuralgia was caused by disease of the origin of the fifth pair. 



4-i FUNCTIONAL DERANGEMENT. 

of some of our gravest and most fearful maladies. The conception we 
have to form of this power is the following: The gray matter contained 
in the spinal cord, medulla oblongata, and associated cranial gangliform 
masses, constitutes a great system, which Dr. Marshall Hall terms the 
true spinal, as distinguished from the cerebral, the latter consisting 
especially of the hemispherical ganglia. Now, whereas voluntary motion 
is produced by the will operating a certain change in the gray matter 
of the hemispheres, which change communicates an impulse to the inter- 
woven nervous filaments, to be conveyed by them to the point of origin 
of the nerve to be affected, and so along this to the muscles, the mode 
in which reflex action takes place is different. A change, generating 
an impulse, is also produced in the gray matter; but it is not in the 
gray matter of the hemispheres, but in that of some part of the spinal 
centre; and the excitor of the change is not the immaterial mind, but a 
physical change in some centripetal nerve, induced by some stimulus 
applied to its extremity, and propagated along it to the point where it 
is implanted in the ^dynamic centre. The motor impulse thus excited 
may affect some adjacent muscular nerve, or be communicated to others 
implanted in some other part of the spinal centre. The use of this 
power is clearly for the constant maintenance of certain muscular 
actions, necessary to life, and the protection of important parts, which 
could not have been left to the uncertain agency of volition. In a cer- 
tain part of this centre, that termed the mesocephale, emotional im- 
pulses appear to be particularly resident, and to be called forth by the 
nerves herein implanted. In the natural condition, scarce a single reflex 
act takes place that is not attended with sensation. The same impression 
that determines the movement, takes effect also as a sensation; but if 
the communication with the hemispheres be cut off, or consciousness be 
suspended, the reflex actions take place quite independent of sensation. 
So also the will has power over many of the muscles, which are under 
the sway of reflex action; but if volition be cut off, the actions are still 
carried on, nay, they cannot be prevented, by any exercise of the will. 
Reflex action may thus be regarded as an " imperium in imperio," and 
as absolutely dominant within its own territory. To the power of re- 
acting upon motor nerves — i. e. of generating an impulse within itself, 
on the reception of a centrifugal impression, which resides in the spinal 
dynamic matter — Dr. Todd has given the name of polarity. The term 
is an expressive and convenient one, and we shall adopt it. Now this 
power is capable of being enormously increased, both as regards its sus- 
ceptibility of being aroused by stimuli, and also as to the extent in 
which it is exerted, and the potency of its action. Under ordinary 
circumstances, the voluntary muscles are, speaking generally, exempt 
from its influence; but in some diseases they are so overmastered and 
controlled by it, that the will is almost powerless over them. At the 
same time the polar susceptibility is so greatly increased, that every- 
thing, even a breath of air, operates as a stimulus, and the dynamic 
matter, like a powerful battery, discharges its impulses with terrible 
force through the motor nerves upon the muscles. This condition of 
the spinal centre can be produced artificially by the administration 
of certain poisons, especially strychnine, which seems, indeed, when 



FUNCTIONAL DERANGEMENT. 45 

given in a sufficiently large dose, to exalt the polarity immediately 
on its reaching the cord. In Mr. Blake's experiments, twelve or six- 
teen seconds only elapsed from the time when the poison was injected 
into a vein, until convulsions commenced, the proof of the cord having 
been already affected. This fact, as well as results of Dr. Todd's 
examination of the spinal cords of animals who died from the effects of 
strychnine, show conclusively that inflammation has no share in the 
production of the phenomena, and that the essence of the malady is 
purely an unnatural exaltation of the normal polarity. Tetanus, 
whether idiopathic or traumatic, is precisely identical with the condition 
induced by strychnine, and, like it, proves fatal, either by utter gene- 
ral exhaustion, or by unrelaxing contraction of the respiratory muscles, 
and consequent suffocation. Chorea is an analogous state, in which 
volition and the spinal polarity seem to maintain a doubtful contest for 
dominion over the muscles, which are usually subject to the will. Hys- 
terical convulsions are often dependent on some cause of irritation in 
the intestines. The impressions conveyed from hence excite the unduly 
susceptible emotional centre; and while they produce the peculiar 
psychical phenomena, are also reflected upon the muscles in impulses 
to convulsive action. In eccentric epilepsy, the mode of causation of 
the attacks is essentially similar ; but it is probable that a different part 
of the spinal centre is affected. It is possible that, in centric epilepsy, 
the attacks depend on a periodical exaltation of the polarity of the 
centre, in consequence of which, as in tetanus, the slightest impressions 
excite the most powerful motor impulses. In early infancy, the cere- 
bral system has not acquired that predominance over the spinal which 
it is subsequently to attain ; and, moreover, the process of dentition, as 
well as the delicacy and susceptibility to disorder of the intestinal 
mucous membrane, seem both to excite the polarity of the cord, and to 
furnish causes of irritation, which, acting on the excited centre, occasion 
the convulsions which are so common a manifestation of nervous dis- 
order in children. One very frequent and important instance of this 
kind of disorder deserves particular notice. Delicate and weakly 
children not uncommonly are affected with spasmodic contraction of 
the glottis, more or less complete. In its slighter degrees, this pro- 
duces a kind of crowing sound, from the rush of air passing through 
a narrowed orifice. In its extreme degree, the glottis is completely 
closed; no air can be drawn into the chest, and the countenance turns 
livid. In this state death may occur, or the spasm may suddenly relax, 
inspiration be effected, and the imminent peril escaped. The system, 
however, remains in the same state of polar tension, and life is in serious 
danger from the frequent recurrence of such attacks, any one of which 
may prove fatal. How obscure would be the pathology of this disease, 
without the clear light which Dr. Marshall Hall's discovery has shed 
upon the subject ! He points out how it originates in the trifacial nerve 
in teething, in the pneumogastric in over or improperly fed infants, in 
the spinal nerves, in cases of constipation, intestinal disorder, or cathar- 
sis. These act through the medium of the spinal centre, from which 
motor impulses are reflected upon the inferior laryngeal, and, in some 
cases, perhaps, on the intercostals and phrenic nerves also. It is worth 



46 FUNCTIONAL DERANGEMENT. 

remarking, that general debility, which increases sensibility, seems also 
to favor the increase of polarity. The condition of grave inflammation 
is not that which seems most to promote the occurrence of reflex phe- 
nomena. The cough, in a case of pneumonia, or pleurisy, is often not 
nearly so distressing as that which follows upon some trifling catarrh, 
when some flake of acrid, irritating mucus, is lodged in the follicles of 
the upper part of the trachea, or larynx, and not being easily detached, 
keeps up a perpetual excitement of the incident nerves, which is 
reflected upon the motor to the expiratory muscles in ceaseless impulses 
to cough. Many other instances might be referred to, but enough has 
been said to show that the idea of polarity and its disorders should 
never be absent from the mind of the rational physician. Instances of 
defective polarity are not unfrequent, though less striking than those 
of increased. Such a state is observed in some cases of fever, where the 
blood seems incapable of maintaining the natural power of the medulla, 
in consequence of which the impressions conveyed by the pneumogastric 
are feebly responded to, and require the occasional assistance of volun- 
tary inspiratory efforts. The same is observed in some diseases affect- 
ing the head, and hence this peculiar kind of respiration has been called 
cerebral. The following quotation, from Dr. Williams's work, contains 
all that can be -said upon the subject: "A failure of this function, 
similar in kind, but less in degree, is exhibited in all states of ex- 
treme debility, whether from excessive fatigue or excitement, or from 
directly depressing and sedative influences, as in adynamic fevers. A 
person in this state is too weak to sleep, for the medulla, partaking of 
the general exhaustion, cannot maintain the respiration without assist- 
ance from voluntary efforts. Hence the feeling of oppression and the 
frequent sighing, which banish all repose; or if sleep do occur, it is dis- 
turbed by startings and fearful dreams, occasioned by the painful 
sensations of imperfect breathing. 

Derangements of Nutrition and Secretion certainly constitute pri- 
mary elements of disease. Of the former, we shall speak particularly 
when we describe the various degenerations that affect the different 
organs. The latter will be considered in detail under the head of the 
several secreting organs and their respective products. We shall now 
only offer a few general remarks on these derangements and their 
effects. Nutrition and secretion are evidently in great measure pro- 
cesses of identical nature. The chief difference is, that in the latter 
a considerable part of the nutrient supply is conveyed out of the organ 
by tubular channels, more or less altered from the form in which it 
exuded from the bloodvessels. The processes of secretion in the 
different instances presented by the system are not all exactly alike, 
the pulmonary secretion, and the urinary in part, seem to pre-exist 
ready formed in the blood ; the biliary and the gastric, as well as the 
seminal, must be formed in their respective glands. It seems probable, 
however, that in all cases an appropriate blastema is requisite for the 
due performance of the function of the organ, and that this contains 
either the secretion ready formed, or principles which are in course of 
change, or ready to change into it. Part of the secreting process is, 
therefore, accomplished in the blood, part in the several glandular 



FUNCTIONAL DERANGEMENT. 47 

organs; and the proportion which these bear to each other varies in 
different instances, and perhaps to some extent in the same. In nutri- 
tion, there seems scarce any reason to believe that the tissues produce 
any very considerable change on the blastema supplied to them, the 
sarcous elements of muscle are but slight modifications of albumen, the 
bones receive phosphate of lime ready formed in the blood, the nervous 
matter is chiefly a compound of oil and albumen, the various pigments 
are probably modifications of that of the blood-globules ; and even 
those which depart most widely from the composition of the blood, the 
various gelatin-yielding tissues, may fairly be regarded as having no 
very distant connection with the Protein compounds. Now it is a 
point of prime importance to remark, that, in both the nutritive and 
secretive processes, the failure or imperfect performance of the function 
■ in any one instance produces an injurious effect on the circulating 
blood. For the nutrition of a part does not imply merely the with- 
drawing of a certain amount of Liq. Sanguinis, and its appropriation 
to that part, but the separation of a fluid differing qualitatively more 
or less from the general current, in consequence of which certain ele- 
ments are retained in, and become, therefore, more abundant in the 
blood. Now if the proper selection of material does not take place in 
the maintenance and repair of different tissues, it is manifest that the 
composition of the blood must be altered. Again, nutrition involves 
the decay of tissues, and the reabsorption into the blood of their effete 
parts ; from which it is clear that, on the due performance of what Dr. 
Prout calls secondary destructive assimilation, the healthy condition of 
the blood is in part dependent. No doubt there are physiological 
limits, within which the nutrition of different parts may vary ; but if 
these are exceeded, disorder, first of the blood, and subsequently of 
other parts, must ensue. It is difficult to point out positive examples 
of disease arising from such causes, but it seems right to refer to them, 
as they may probably lie at the bottom of many obscure and ill-defined 
morbid states. With respect to the secretive processes, we have familiar 
instances of their disorder producing injurious effects on the blood, and 
through it, upon other parts. If the liver become sluggish in its action, 
and bile is not properly excreted, the countenance betrays by its tinge 
the unnatural state of the blood, and the loss of appetite and headache 
testify that the stomach and the brain are secondarily affected. If the 
texture of the kidney be spoiled, and the secretion of urine in conse- 
quence be seriously interfered with, the urea is retained in the blood, 
and this fluid becomes thus so altered in its composition, that the red 
globules are no longer properly developed, and the patient presents a 
sallow, anemic aspect, while at the same time inflammations are ex- 
ceedingly apt to arise in various parts, owing to the disordered nutrition 
induced by the unhealthy blood. If the secretion of a gland be 
greatly increased, though of perfectly natural composition in itself, 
this increased outflow becomes a drain upon the system, and thus a 
cause of debility. Diabetes may be referred to in illustration of this, 
as, although an unnatural substance, sugar is added to the urine, yet 
its own composition is not materially altered. Another very striking 
instance is afforded by cases of asthenia lactantium, the continued drain 



48 FUNCTIONAL DERANGEMENT. 

from the mammary glands exhausting the frame and all the vital ener- 
gies in a fearful manner. Secretions excessive in quantity, and more 
or less unnatural, also produce great debility ; of this, we have frequent 
examples in profuse diarrhoea or leucorrhcea. The material of these 
fluids is of course so much withdrawn from the circulation. Unnatural 
secretions often produce irritation and disturbance of parts with which 
they come into contact. Thus acrid bile produces severe diarrhoea ; 
diarrhoeal and leucorrheal discharges often excoriate the integument 
around their respective outlets, highly acid urine causes a sensation of 
scalding in the urethra, or even may give rise to attacks resembling 
nephritic colic. Deficient quantity and disordered quality of a secre- 
tion, often go together ; thus scanty urine is generally morbid in some 
other respect ; the opposite condition, however, is quite as frequent, 
and the secretion, though plentiful, is very unnatural. Of the latter 
condition we have examples in debilitated persons who pass large quan- 
tities of pale, alkaline urine, containing triple phosphate. The former 
state is constantly observed in the commencement of various febrile 
affections. The nervous system has a considerable influence over the 
various secretions. Great agitation has been known to cause a mother's 
milk to assume a poisonous quality, or such, at least, as to occasion in 
a few minutes the death of the infant. A similar cause has produced 
jaundice rapidly in some persons, and in others a bilious diarrhoea. 
After an hysterical fit, a large flow of pale, almost aqueous, urine is 
passed. A flow of tears is the natural effect of the passion of grief, 
and a flow of saliva of the expectation of a meal. Appetite is imme- 
diately destroyed, i. e. the secretion of gastric juice arrested, by sudden 
distressing intelligence. The lessons which these facts convey can 
scarcely be too much appreciated. They show us that we must never 
forget the wonderful but intimate connection that exists between our 
material and immaterial part, and that it is fruitless to strive against 
the incessant influence of a down-weighed or wounded spirit by doses 
of drugs. These cannot "cleanse the stuffed bosom of that perilous 
stuff which weighs upon the heart." Instances are occasionally met 
w r ith, in which some secretion is manifestly unnatural, and yet there is 
no constitutional disturbance. It appears as if some morbid matter 
were carried off by this channel, the removal of which left the system 
in health. Of this kind are cases of fetid secretion from the feet, 
some of oxalate of lime in the urine, and perhaps the naturally foul 
breath which is habitual to some persons. It is very probable that 
several disorders, among which may be particularly mentioned gout 
and rheumatism, essentially depend, partly on a mal-performance of 
that part of the function of secretion which takes place in the blood, 
and partly upon defective elimination ; so that various effete matters, 
not undergoing those oxidating changes which ' they normally should, 
and being, instead, partly converted into other more noxious and un- 
natural principles, circulate in the blood for some time, producing 
general uneasiness and malaise, and, sooner or later, break out in an 
eruption of morbid matter, by the skin, or some other emunctory. The 
gouty paroxysm, with its foregoing ill-health, is the rtapaSaiy^a of this 
condition. It is also illustrated in rheumatism, and more or less in 



FUNCTIONAL DERANGEMENT. 49 

other morbid states of the system, to which the appropriate name of 
Excrementitious Plethora has been applied. Dr. Williams observes, 
that he has often found purpura connected with hepatic congestion and 
imperfect excretion of bile, and most effectually removed by remedies 
which promote the restoration of the proper secretion. It is not un- 
frequently seen that the sudden arrest of a secretion, though it be a 
morbid one, which has continued long, and produced a considerable 
drain on the system, is attended with serious, nay, even fatal effects. 
These probably depend on the establishment of a condition of plethora, 
not, indeed, such, as under ordinary circumstances would deserve the 
name, but which is felt as such by the debilitated, and perhaps sensi- 
tive, system. When this state exists, local congestions are very apt to 
occur, and may end in fatal extravasation of blood in the brain, if that 
be the part affected. If the natural secretion of a gland be in any 
way greatly diminished, a state of congestion of the organ is very apt 
to follow; the converse occurrence also is often observed, and it is not 
by any means always to be discerned clearly which of the two is to be 
regarded as the cause, and which as the effect. The temperature of a 
part whose natural secretion is arrested, is almost always higher than 
natural. No more marked instance can be mentioned of this than the 
skin in many fevers. Remedial means, which diminish the quantity of 
blood in a congested part, often restore or increase the secretion which 
had been interrupted ; and conformably to this, we often observe in 
cases of profuse abnormal secretion, that the surface from which the 
flux takes place, instead of being red with blood, is unnaturally pale ; 
the contents of the vessels seem to be drained away as fast as they 
arrive ; so that one is almost reminded of the old theory of exhalant 
arteries with open mouths. 






CHAPTER II. 

MORBID STATES OF THE BLOOD. 

The saying attributed to Cuvier, "Le sang est chair coulant," 
expresses very fairly the relations that subsist between the nutrient 
circulating fluid and the solid tissues. As we have already remarked, 
a change in the former involves almost necessarily a change in the 
latter, and each of the vital actions of the latter exerts some influence 
on the former. It is manifest, therefore, that an acquaintance with the 
healthy properties and morbid alterations of the blood is absolutely 
essential to a correct study of the phenomena wrought by disease in the 
solid parts. But the blood itself is a very compound thing, not only as 
regards the number of different matters it contains, organic and inor- 
ganic, not only as regards the manifold additions which it receives from 
without in the way of nutriment, and those which are poured back into 
it as the effete residues of tissues, but also as regards its own morpho- 
logical condition being made up of solid and of fluid parts, of organ- 
ized particles floating in an organic liquid. In diseased states of the 
blood these several parts, or some of their constituents, may be 
separately affected,, and it seems, therefore, desirable on this account, 
as well as for the sake of greater precision, to examine first the indi- 
vidual component elements of this fluid with reference to their patho- 
logical changes, and afterwards to consider the diseases of the blood 
taken as a whole. Regarding the blood per se, this inquiry would 
rather belong to special than to general Pathology, but we include it 
under the latter head on account of the manifest general relations of 
the blood. 

RED AND WHITE CORPUSCLES. 



The circulating fluid consists, as we know, of two kinds of organized 
particles, floating in a transparent slightly yellow fluid. The organized 
particles are the red globules, preponderating immensely in number, and 
giving to the fluid its characteristic color, and the white or colorless, 
which in the healthy state occur somewhat "few and far between," and 
impart to the general mass no distinguishable quality. 



JBecquerel and Rodier. 



Corpuscles, red and white 

Water .... 

Fibrin 

Albumen 

Fat, extractive, salts 



In Males. 
141.1 

779.0 

2.2 

69.4 

8.4 



In Females. 

127.2 

791.1 

2.2 

70.5 

9.0 



1000. 



1000. 



RED AND WHITE CORPUSCLES. 



51 



The red globules are vesicles having a distinct homogeneous envelop, 
which incloses a central mass of whitish albuminous matter, and a sur- 
rounding film of red fluid. Their form is circular and biconcave, they 
present therefore cupped surfaces and an 8-shaped edge. They readily 
distend themselves by endosmosis with thinner fluid and assume a 
spherical shape. On sudden pressure being applied, and sometimes 



Fig. l. 




Fig. 2. 







Blood-corpuscles, magnified 400 diameters. 



White Corpuscles of the Blood, magnified 
400 diameters. 



from other causes, they assume a kind of crenate form, conveying the 
idea that the central mass, the so-called globulin, is broken up into a 
number of granules, pushing irregularly outwards the homogeneous 
envelop. The white corpuscles are much larger, nearly double the 
size of the colored ones ; they are spherical, and may often be seen 
when a drop of blood is examined under the microscope, remaining 
motionless and fixed in the field, while the red globules are hurried 
along on all sides round them by the currents which are created in the 
fluid by capillary attraction. No true nucleus can be seen in the white 
corpuscles ;' they seem to consist of a semi-solid mass of albuminous 
matter, inclosed within a delicate envelop. Their function is not cer- 
tainly known; by some physiologists they are regarded as constituting, 
together with the similar corpuscles in the lymph and chyle, transitional 
forms in the development of the red particles. By others, they are 
supposed to be the agent in the formation of the fibrin, which they 
elaborate out of the albumen, imparting to it its peculiar coagulating 
and so-called plastic properties. The use of the red globules is in all 
probability connected with the function of respiration ; this seems well- 
nigh demonstrated by the facts of comparative anatomy, and by the 
marked changes which they undergo in the course of the circulation. 
Liebig has expressed the opinion that they are the carriers of oxygen 
to the various tissues, or, more exactly, the iron which they contain ; 
this element in its protoxide form receiving in the lungs another atom 
of oxygen, and thereby passing into the state of peroxide, while in the 
course of the circulation it again parts with the atom of oxygen in 
exchange for one of carbonic acid, and thus passes into the state of pro- 
tocarbonate. This view may be in part true, but is doubtless too 
exclusive ; there is as much reason to suppose the Liquor Sanguinis to 
be the vehicle of the oxygen and carbonic acid, as the red corpuscles. 



1 Acetic acid brings into view, or produces one, two, or three granules similar to those 
contained in the pus cell. 



52 RED AND WHITE CORPUSCLES. 

Mr. "Wharton Jones believes that the red globules elaborate the fibrin, 
or rather are transformed into it, bursting and dissolving like secreting 
cells. Various plausible arguments have been advanced in support of 
this view, which was first propounded by Dr. Simon, of Berlin, and is 
adopted also by Wagner and Henle ; but it does not appear to the 
writer that it can be considered at all established. Neither on the 
other hand can Dr. Carpenter's be considered proved, though the pre- 
ponderance of testimony seems on the whole to be in its favor; nor is 
there, in short, any positive cause to forbid us to believe that the truth 
may lie intermediate, and that the production of fibrin may be one 
result of the general cell growth taking place in the blood. With 
respect to the red globules, however, this is certainly proved, that their 
amount is, ceteris paribus, proportionate to the vigor, health, and 
strength of the individual. In the examinations made by MM. Andral, 
Gavarret, and Delafond, of the blood of various animals, it was con- 
stantly observed that those which possessed most strength and vigor, 
and were generally the finest specimens of the race, gave the highest 
figures in a series showing the relative amounts of globules ; while those 
that were debilitated and poor showed a corresponding deficiency in 
this particular. Also, when the breed of a species was improved by 
crossing it with another, there was a corresponding increase in the 
quantity of red particles. In the human subject, the comparison of the 
general vigor and activity of the sanguine temperament, both as regards 
body and mind, with the sluggishness and dulness of the lymphatic 
temperament, or with the languor and debility of the anemic patient, 
show that the same rule holds good. In Prevost's and Dumas's experi- 
ments, animals near death from loss of blood, were recovered by an 
injection into their veins of a mixture of red particles and serum. The 
serum alone had not this effect. The proportion of red globules dried 
to 1000 parts of blood, is in healthy males estimated at 127 parts by 
Andral and Gavarret ; lower and higher figures have been given by 
other analysts, but this probably is the result of somewhat different 
modes of proceeding. In females the proportion of globules is lower, 
Becquerel and Rodier make the difference to be about 15 parts per 
1000. The blood of the foetus appears to contain an unusually large 
amount of globules, stated by Denis in the proportion of 222 to 140 of 
maternal ; after birth this gradually diminishes. Plethora is the chief 
pathological condition in which an increase of red globules has been 
observed. One of the cases of cerebral congestion mentioned by Andral 
presented an amount of 138, 6 parts per 1000, an excess of 11 above 
the normal figure ; after venesection, the globules in this case were so 
far diminished that the quantity only amounted to 101, 1 per 1000, 
considerably below the mean. In various febrile diseases, an augmen- 
tation of the globules has also been observed; thus, in the period imme- 
diately preceding the outbreak of continued fever, their amount was 
once found as high as 157.7 ; in the early period of a case of severe 
inflammatory fever, the fourth day of the disease, the globules had 
attained the extraordinary height of 185 parts per 1000, the greatest 
amount ever observed ; in several cases, of typhoid fever (fever with 
intestinal complication) the globules had risen to 142 or even 149, and 



RED AND WHITE CORPUSCLES. 53 

even on the second bleeding -were found still considerably above the 
mean ; in scarlatina and in measles an increase in the amount of 
globules was also found, the maximum (which existed in the latter) 
being as much as 146. No increase was observed in cases of variola or 
of modified smallpox. The condition of the general system coexisting 
with, and probably occasioned by, the increase in the amount of red 
globules is exaltation of the animal heat, heightened sensibility, and 
muscular irritability ; the spirits are high, and the mental energy great, 
the pulse beats full and firm, the power of resistance to debilitating and 
morbid influences is considerable, the tendency in disease is to active 
inflammation and high febrile excitement, and bleeding, if employed, is 
well borne. Probably, a chief cause of danger when the amount of red 
globules is considerably increased, is the simultaneous diminution, or at 
least non-proportionate increase of the fibrin ; hence arises a liability 
to serious hemorrhages in the brain or other parts. The effect of iron 
in promoting an increase of the red globules is well known, but it will 
often fail where the attendant circumstances are unfavorable, and we 
have seen a much more rapid effect produced by the change from a 
scanty to an ample diet. Free exposure to fresh air and light seems 
also powerfully to promote the formation of red blood, as much as the 
deprivation of them tends to destroy it. The opposite condition to ple- 
thora, for which the term spanemia (anavoc, scarce) is more appropriate 
than anemia, is essentially characterized by a deficiency in red globules. 
Extreme cases of this state are by no means unfrequent, and, which is 
not sufficiently known, are by no means unattended with serious danger. 
Sudden death has in several instances taken place apparently from the 
cessation of the heart's action, the debilitated organ being insufficiently 
stimulated by the impoverished blood. In an extreme case of chlorosis, 
Andral found the globules at so low an amount as 38.7 per 1000, the 
water at the same time being increased from 790 to 868.7. Similar 
alterations were found in the blood of other individuals who had become 
anemic from other causes, from lead poisoning, the cancerous or tuber- 
culous cachexia. In Bright's disease, there is evidently a marked failure 
in the power of producing red globules, and the same is the case in the 
peculiar affection termed leucocythemia, which either depends on, or is 
coincident with, great hypertrophy of the spleen. We are inclined to 
think that in spanemic states the red globules are not only deficient in 
number, but defective in quality ; they appear under the microscope 
manifestly paler than those of persons who have a healthy color, their 
hsematin, in all probability, is not properly formed. The well-known 
symptoms of this condition are general debility, diminished temperature, 
palpitation, often excessive, of the heart, and various nervous affections. 
In some of the most malignant fevers the blood-globules appear to be 
actually destroyed ; Dr. Williams has observed this in a case of albumi- 
nuria, proving fatal by purulent infection, and in a case of malignant 
scarlatina; we have examined, the blood a few times in persons dying of 
such diseases, but have not found any noticeable alteration in the 
globules. Hokitansky mentions that he has observed in a septic state 
of the blood an altered condition of the globules, which are swollen up 
from their natural disk-like shape, and have parted with much of their 



54: RED AND WHITE CORPUSCLES. 

hoematin to the surrounding fluid. The red globules, as has been men- 
tioned, are very liable to be affected by the fluid in which they float; when 
this is dilute, they distend themselves by endosmosis, and become spheri- 
cal, while the mass at the same time assumes a dark red color. By the 
addition, however, of concentrated saline solutions, the bright red color 
is again restored, and the corpuscles again assume their biconcave form. 
When carbonic acid is added to arterial blood, the corpuscles change 
their biconcave for the biconvex form, 1 and the color at the same time 
changes from red to black. On these facts, Scherer and Nasse maintain 
the theory that the alteration of color in the blood which is effected in 
the lungs, depends upon an alteration in the form of the corpuscles, the 
biconcave disks acting as concave mirrors, which collect the reflected 
rays instead of dispersing them as convex surfaces do. Whether this 
theory be true or not, the facts it records are certainly worth remem- 
bering, as a distended state of the corpuscles, by whatever cause occa- 
sioned, must greatly increase the liability to the occurrence of local 
congestions. When the fluid in which the corpuscles float is more 
aqueous than natural, the red fluid which they contain passes out of 
them by exosmosis, and mingles with the serum. When this is the case, 
the walls of the vessels, and the tissues in immediate contact with them, 
very commonly become saturated with a red color, which must be care- 
fully distinguished from that which accompanies inflammation. The 
effect of diluting the Liquor Sanguinis upon the blood-globules is 
exceedingly well shown by an experiment performed by Mr. Lane. An 
animal was bled, and the serum, after the formation of the clot, was, as 
usual, colorless, or of a light yellow ; a certain quantity of matter was 
then injected into the veins, and soon after blood was again drawn. 
The serum of this, however, was of a decided red, contrasting strongly 
with that of the preceding quantity. It was, therefore, quite clear, that 
the hrematin had been removed from the globules, and dissolved in the 
serum. We have observed the same thing with the microscope in the 
blood of frogs, and in that of foetal vertebrata. When the globules 
have not been exposed to the action of water, or only in a slight degree, 
the space between the envelop and the nucleus is filled with red fluid, 
which almost or entirely conceals the latter ; but when water has been 
freely added, the red fluid entirely disappears, and the nucleus comes 
clearly into view. It seems very probable, as Dr. Williams suggests, 
that the instances of sudden death occurring immediately after copious 
draughts of cold water in an exhausted state of the system, have been 
in some measure owing to such alterations of the blood-globules, as we 
have just noticed. The same changes may also be concerned in the 
phenomena consequent on excessive losses of blood, especially in occa- 
sioning the local congestions which are apt to take place in them, and 
in the anemic generally. The red globules of human blood exhibit a 
tendency to cohere together in such a manner as to form tolerably 
regular piles, or rouleaux ; in the healthy condition the cohesion soon 
ceases, and is not nearly so strongly manifested as in the inflammatory 
state. Of this, indeed, it is quite characteristic that the globules form 

1 The authors of the Physiological Anatomy, however, do not confirm this statement. 



RED AND WHITE CORPUSCLES. 



55 



rows of some length, made up of numerous disks cohering together by 
their surfaces, and having their edges disposed 
so as to form a tolerably straight line. The 
cause of this tendency is not certainly ascer- 
tained, but the phenomenon seems to give some 
countenance to the opinion of Mulder, that the 
red corpuscles become invested in the lungs with 
a film of oxidized protein matter, which is found 
more abundantly in inflammation, and may cause 
the adhesion of the particles to each other. 



There must, however, be some further reason 




Blood-corpuscles, magnified 400 
diameters. 



why the disks should so exactly adapt them- 
selves to each other face to face. 

While so much uncertainty prevails respecting the origin of the red 
corpuscle, it is not possible to point to any foregoing condition as 
specially tending to promote their growth and increase, or to occasion 
their atrophy. All that can be said is, that a proper constitution of 
the Liquor Sanguinis is certainly essential, as being the material out 
of which these floating cells are nourished and built up. If this be im- 
poverished, or otherwise deteriorated, the corpuscles will not be properly 
developed ; and again, by improving the quality of their plasma, their 
healthy condition will be restored. Of this, we have a good example in 
those cases of chlorosis, where the administration of iron is sufficient 
to reproduce the ruddy hue of the complexion. In other cases, a de- 
fective state of nervous influence, proceeding from some mental affec- 
tion, occasions the atrophy of the red particles ; but we cannot tell 
whether this cause acts upon them primarily, or, as is more probable, 
through the medium of other organs and functions. There can be no 
doubt that the blood-globules have an appointed period of existence, 
after which they naturally decay. This decay probably takes place in 
the general course of the circulation, at least in part. Evidence, how- 
ever, has recently been adduced to show, that the spleen is especially 
the seat of a destructive process, affecting the globules ; and that the 
yellow pigment matter, so frequently found in this organ, is, in fact, 
the remains of their altered haematin. In the liver, also, the blood- 
globules seem to yield up their coloring matter, to furnish the yellow 
pigment of the bile ; and the coloring matter of the urine is no doubt 
derived from the same source. The circumstance that so much pig- 
mentary matter should, by these two channels, be ejected out of the 
system, shows, on the supposition that it is derived from that of the 
red globules, how rapidly the latter must undergo decay ; and, by con- 
sequence, how fast their reproduction must take place. It is worth re- 
marking, that one drug, the most commonly used, perhaps, of all, 
seems to have almost as much tendency to cause the destruction of red 
corpuscles, as iron has to promote their formation. This is mercury, 
under a course of which, as Dr. Watson mentions, a patient was 
blanched as white as a lily, who previously had a complexion com- 
pounded of the rose and the violet. The non-depuration of the blood 
mass exerts an injurious influence upon the development of the red 
globules, as well as upon its other constituents. The effect of some 



56 RED AND WHITE CORPUSCLES. 

diseases of the spleen and of the uterine system, which have been ob- 
served to be especially connected with an anemic state, may be ex- 
plained on this principle. A quantity of blood congesting, and dis- 
tending the venous channels of the spleen, is detained there longer 
than it normally should, and becomes more or less impaired in its com- 
position and spoiled, so that when it again returns to the circulation, or 
any portion of it is conveyed thither, it acts after the manner of a 
poison upon the remaining blood mass, corrupting and contaminating 
it, and thus inducing general cachexia. Suppression of the menstrual 
discharge seems to act much in the same way, the blood not undergoing 
its periodical depuration, contains a quantity of effete matter, which 
reacts injuriously upon it, and, after a time, produces a manifest altera- 
tion from its healthy composition. 

Of the morbid changes of the white corpuscles, we know indeed very 
little positively. Their number is, we think, increased in inflammation, 
but perhaps not to the degree that it has often been supposed to be. 
Mr. Wharton Jones remarks, that the quantity of white corpuscles 
existing in the blood naturally, has been estimated at less than it really 
is ; and that, on the other hand, the accumulation of colorless corpus- 
cles in the vessels of an inflamed part, and in the buffy layers' of co- 
agulated blood, has been referred to as proving the existence of a like 
quantity in the general mass of the blood. In blood from a pregnant 
female in the eighth month, the quantity of white corpuscles appeared 
to me to be increased, and their contents also less finely mottled, and 
more granular than in those of ordinary blood. In leucocythemia, the 
quantity of colorless corpuscles appears to be enormously increased, 
and their size exaggerated ; but some doubt may be entertained whether 
these colorless corpuscles are of the same nature as those normally ex- 
isting. In pyaemia, Lehmann says, that the colorless corpuscles are 
increased. Some of those observed, however, may have been of puri- 
form nature. 

There does not appear to be any positive instance of diminution of 
the colorless corpuscles. 

Having discussed the pathological changes of the corpuscles or cells 
of the blood, we next come to consider those of the fluid in which they 
float. This fluid, the Liquor Sanguinis, consists of a watery solution 
of certain inorganic salts, in which there are besides dissolved a large 
proportion of organic substances. These are distinguished into fibrin, 
albumen, extractive matter, and oil. We shall consider each of these 
separately. 

When fresh-drawn blood is left to itself, it very soon, as we know, 
passes from a liquid state into that of a solid mass ; it coagulates. 
This change can be conclusively shown to be occasioned not by the 
corpuscular elements cohering together, as was once supposed, but by 
the solidification of one of the constituents of the fluid portion of the 
blood. Miiller's experiment of filtering frog's blood, so as to separate 
the corpuscles, was decisive as to this point. The substance which thus 
spontaneously solidifies is termed fibrin, and the name evidently has 
reference to an inherent tendency which it possesses of assuming a 
fibrous arrangement. Fibrin, when separated from healthy blood, is 



RED AND WHITE CORPUSCLES, 



57 



a tough, tolerably firm, elastic, stringy, whitish-gray-looking substance. 
It is insoluble in water, and sinks in this fluid, or even in the serum 
from which it has been separated. Under the microscope, it appears as 
an homogeneo-granular blastema, or basis-substance, with more or less 
marked tendency to fibrillate, or form actual fibres. The white cor- 
puscles of the blood are very commonly seen imbedded in the fibrinous 
mass, but they do not appear to contribute to modify its character. 
This, at least, is true of healthy fibrin; of diseased we shall presently 

Fie. 4. 




fibrils of Healthy Fibrin, entangling red and white blood-corpuscles (three of the latter are figured 
separately), and a few fibrinous fibrils. 

speak. Lehmann describes as follows the actual process of coagulation 
of the fibrin as seen under the microscope. He says : " There ap- 
pear here and there individual points of molecular granules, from out 
of which very soon extremely fine straight threads spring, which go off 
in a radiating manner from that point, but do not form star-shaped 
masses, as in crystallization ; these threads elongate themselves grad- 
ually more and more, and cross with those which have proceeded from 
other solid points, so that at last the whole field of view appears, as it 
were, covered over with a fine, but somewhat felted network. After- 
wards this network still proceeds to thicken, and the colorless corpus- 
cles imbedded in it are often scarcely perceptible." With regard to its 
chemical composition, Lehmann remarks very properly, that fibrin, 
such as we obtain, cannot by any means be considered as a pure sub- 
stance ; it must contain the white corpuscles, and probably some amount 
of albumen and extractive matter. However, such as we find it, all 
the chemical difference between it and albumen appears to be, that 
there is a small quantity more oxygen in it than in albumen. This 
fact testifies strongly that fibrin is characterized much more by its 
vital endowments than by its peculiar composition, and would lead us 
to regard it as a modification of the albumen of the serum produced 
for some special purpose. This may be, in part, to give to the fluid 
portion of the blood a proper degree of spissitude, so that the corpus- 
cles are better sustained and mixed with it, and that the circulating 
stream passes more readily through the capillary channels than it would 
do if it were more dilute. One very important end which the fibrin 
serves, is the formation of coagula at the orifice of wounded vessels, 
preventing the occurrence of further hemorrhage ; and this is well illus- 



5S RED AND WHITE CORPUSCLES. 

trated by those instances occasionally met with of almost irrepres- 
sible hemorrhage from the slightest wound, in which it seems pretty 
certain that their blood must be very deficient in healthy fibrin. But 
a still higher dignity has been assigned to the fibrin ; it has been re- 
garded very generally as the plastic material, par excellence, from 
which all the tissues are formed, and the small amount of it present in 
blood was supposed to show that it was constantly being drawn off for 
the nutrition of the tissues as fast as it was formed. Of late years, 
however, much evidence has been adduced, which at least goes some 
way to establish an opposite view, and throws considerable doubt on 
the correctness of the old opinion. We will review the arguments on 
both sides. 

In support of the specially plastic and organizable character of fibrin, 
it is argued that it seems to be by its means that the reparation of wounds 
is effected. A thin layer of coagulating, fibrillating material is the me- 
dium which unites and holds together the divided surfaces, and forms 
the first organic connection. So also when a fluid containing much 
fibrin is effused on the surface of serous membranes, it very commonly 
forms bands of adhesion passing between the opposed layers. These 
new-formed structures resemble very much normal, white, fibrous tissue. 
There is evidence to show that layers, and even masses of fibrin,' are 
capable of being organized; so far, at least, as to become fibroid tissues, 
and that vascular networks are developed in them. Andral mentions a 
case of apoplectic effusion in the substance of the brain, in which — death 
having occurred many years after — a mass of pale red color, and fibrous 
appearance, and traversed by numerous small bloodvessels, anastomosing 
with those of the brain, was discovered. M. Louis has recorded the 
occurrence of a vascularized coagulum in a tuberculous cavity in the 
lungs; and many similar instances have been noticed, in which the fibrin 
of effused blood has evinced its capacity for organization. But how lowly 
is this organization ; never in any known instance amounting to more 
than the formation of a fibrous tissue, more or less closely resembling the 
natural. This, almost of itself, is a proof that fibrin is not the pecu- 
liarly organizable and plastic element that it has been considered to be. 
It may also be said that albumen, which is the only other organizable 
constituent of the blood, shows no tendency, even when collected in 
large quantity, as in the fluid of ascites, to pass into any organized form; 
while fibrin, when effused, does at least assume the appearance of a 
lowly organized tissue. The condition, moreover, of the fibrin seems 
to be in some manner an indication of the vigor and health of the sys- 
tem. If it contracts well, and forms a firm, dense clot, there is reason 
so far to conclude that the constitution is sthenic and unbroken ; but if, 
on the contrary, the clot be soft and easily broken up, the system is 
probably in an opposite condition. The above statements seem to amount 
to this, that fibrin is certainly capable of assuming a low type of or- 
ganization ; but they entirely fail to show that it is the special blood- 
constituent which is applied to the nutrition of the different tissues, and 
that therefore its abundance is a sign of vigor and health. 

On the other side, the counter-evidence which we have to adduce is 
certainly of great force. Bleeding, which we saw to have a powerful 



RED AND WHITE CORPUSCLES. 59 

effect in diminishing the quantity of red corpuscles, has none such upon 
the fibrin; nay, it rather seemed to tend to increase it. In Andral's 
ninth case of articular rheumatism, the fibrin at the second bleeding 
was 7, and at the third 6, while in the first it was 5.4. In the tenth 
case, at the fourth bleeding, it presented the extraordinary figure of 10.2 
per 1000, while in the first it did not amount to more than 6.1. The 
globules, however, were reduced by the three subsequent bleedings from 
123.1 to 101.0. Starving also, instead of lessening, was found to in- 
crease the quantity of fibrin. An increase in this element was found 
in meagre, half-starved horses, amounting to as much as 7 or 8 be- 
yond the healthy mean; and in one case, where no food was given for 
four days, the quantity of fibrin was found increased from 5 to 9. 
On the other hand, the improvement of a species which we found to be 
marked by an increase in the proportion of globules, seems to be also 
characterized, though less strongly, by a diminution in the quantity of 
fibrin. The average quantity of fibrin in a flock of sheep of pure blood 
was determined by Andral to be 3.1; in a cross-breed flock, the average 
was only 2.8. The blood of the foetus and of the new-born animal, 
in whom certainly development and growth are proceeding rapidly, 
and in whom there must, therefore, be a constant demand for plastic 
material, is rich in globules, but poor in fibrin. Andral found in lambs, 
during the first twenty-four hours after birth, a proportion of fibrin 
only amounting to 1.9 per 1000 ; at the end of the fourth day, it had 
risen to 3.0 parts. This observation, as well as the familiar effect of 
diseases preventing the due oxygenation of the blood, in causing it to 
remain fluid after death, which seems to imply the non-formation or 
destruction of the fibrin, points very clearly, as it seems to us, to the 
conclusion that fibrin is an oxidation-product, and rather belonging to 
the descending series of destructive assimilation, than to the ascensive, 
plastic, and formative. 

That fibrin takes an important part in the reparative process cannot 
be doubted; we constantly find it forming the uniting medium between 
divided parts, but have we any evidence that it becomes further deve- 
loped, and passes into the form of any tissue more highly organized than 
that of the cicatrix ? Surely, there is not the least ; or rather, all that 
we know of the process of reparation tends to contradict such an idea. 
The case of a divided nerve serves to illustrate this point very well. 
Within a short time after the operation, the cut ends of the nerve are 
united together by fibrinous effusion, which has solidified round them ; 
this passes afterwards on into the form of imperfect fibrous tissue, and 
so the apparent continuity of the nerve is restored. But we know that 
it is not really restored until very much later; we know that many 
months must elapse ere the severed nerve-tubules can be again connected 
by their own proper tissue, and their function restored. Now in this 
really reparative act there is no reason to believe that fibrin takes any 
prominent part, that it is at all more concerned than the albumen and 
oily matter of the blood, which are the elements chemically considered 
of which the nerve-matter actually consists. In the same way, in every 
organizing act in which there is more than the mere coagulation of 



60 RED AND WHITE CORPUSCLES. 

fibrin, albuminous serum is also present, and we have no reason to ex- 
clude it from participating in the formative process. Once more, if we 
take instances where deposition of fibrin has almost exclusively taken 
place, do we find development and growth proceeding actively in these 
deposits or not? The well of an aneurismal sac is often lined with 
dense layers of coagulated fibrin, and yet Professor Simon testifies that, 
on the most careful examination of these layers no trace whatever is to 
be found of new organization. So it is with the masses of fibrin that 
are deposited in the spleen, the kidney, and in other parts. They show, 
after a time, a tendency to retrograde and dissolve, but none to develop 
into any higher grade. The small, fibrinous, sub-pleural nodules often 
seen in tolerably healthy lungs, are favorably circumstanced as regards 
vascular supply, for growth and further development, but they do not 
appear to enlarge, or manifest any vital activity*. The deposits of fibrin 
upon the valves of the heart, the wrongly-called vegetations, in like 
manner show no innate capacity of development and growth; they 
tend to contract and harden, or to become penetrated with calcareous 
matter, and never show any organized arrangement beyond a low grade 
of fibrousness. 

The circumstance which seems to have contributed most, or at least 
very highly, to establish the opinion of the highly plastic quality of 
fibrin is, that its quantity is found to be so very largely increased in 
sthenic inflammatory diseases. Not only its appearance in the thick, 
buffy coat, but the quantity of solid effused matter, forming layers of 
false membrane, of considerable firmness and thickness, together with 
the character of the attendant symptoms, inspired an idea that the sub- 
stance thus abounding in these diseases of marked sthenic type, and so- 
called increased action, and comparatively deficient in affections of 
asthenic type, was that which was especially plastic, and employed in 
the construction of all the various tissues in healthy nutrition. Dr. 
Williams says of fibrin, that it is a representative of the active state 
of the processes of reparation, circulation, innervation, and of those of 
nutrition and reparation, and that " it therefore exists in larger pro- 
portion and higher perfection in arterial than in venous blood." Dr. 
Carpenter, mentioning the solvent power which a solution of nitre has 
upon fibrin, remarks, that this only applies to venous fibrin, and that 
arterial fibrin is not thus soluble. As the solution of venous fibrin 
is coagulable by heat, it appears to resemble albumen, but the insoluble 
precipitate which it lets fall on exposure to the air, seems rather to 
possess the properties of arterial fibrin. "Hence," he adds, "it may 
be inferred, that the fibrin of venous blood most nearly resembles albu- 
men, whilst that of arterial blood and of the buffy coat contains more 
oxygen, and is more highly animalized." We cannot agree with this 
inference, as an increased degree of oxidation is rather a sign of de- 
struction than of development, at least as applied to the tissues. More- 
over, the facts do not seem altogether established ; Lehmann says that, 
in the human subject, whether it were taken from venous, or arterial, 
or inflammatory blood, he has found the fibrin soluble in nitre solution, 
excepting two cases of inflammatory blood. Pig's blood fibrin, whether 
arterial or venous, dissolved equally well and very quickly. This sup- 



RED AND WHITE CORPUSCLES. 61 

posed difference between arterial and venous fibrin is not constant. 
Thus much for the " higher perfection." As to the greater quantity 
•which is found in arterial blood, it may be observed, (1.) That it is quite 
possible that it is employed to feed the various excretory glands, and is 
thus thrown off from the system, so that it exists in a less proportion 
in the returning venous current. (2.) That if arterial blood contains 
more fibrin, it contains also less albumen 1 than venous, so that, regard- 
ing fibrin as a product of oxidation, this is no more than might be 
expected ; the fibrin being reconverted into albumen in the venous 
blood. 

We shall conclude this discussion as to the nature of fibrin, with the 
following quotation from Rokitansky, whose testimony on this point 
cannot but be regarded as of considerable weight : " Considering the 
frequency of solid fibrinous blastemata as the basis of pathological new 
formations, compared to their rarity in the physiological condition, and 
referring also to the predominance of the development of the tissues 
out of cells in the physiological condition, and to the deficiency of fibrin 
in the embryo, we cannot suppress the declaration, that we are inclined 
to see (w T ith Zimmermann) in fibrin really an excretory formation, a 
substance brought by oxidation nigh to the state of disintegration, an 
albuminous matter consumed by oxidation, which together with albu- 
men appears only in the form of pseudo-fibrin to be any longer applied 
to nutrition." While thus rejecting the doctrine that fibrin is the sole 
or chief plastic element, we do not wish, on the other hand, to deny its 
importance when of proper quality in maintaining the due consistence of 
the blood, and in fulfilling such other purposes as those at which we have 
glanced. We now proceed to consider the variations of this substance, 
in different morbid conditions as to quantity and quality. v 

The average for the fibrin of ordinary venous blood, adopted by 
Andral, is 3 parts per 1000, but most observers place it rather lower. 
Scherer found in the blood of Wealthy men 2.03 — 2.63 parts. Its 
quantity as mentioned is greater in arterial than in venous blood, and 
is said by Schmid, after numerous examinations, to be only one-third in 
portal venous blood of its ordinary amount in that of the jugular vein. 
Sex does not appear to affect the proportion of fibrin, but the state of 
pregnancy does materially ; in the first six months the quantity is de- 
creased, the average being 2.3; during the last three months the quan- 
tity is increased, so as to average 4. After parturition, the quantity for 
a time seems to be still further increased; a circumstance which may 
have some relation to the tendency to uterine inflammation, and mam- 
mary abscess, which marks this period. In very early infancy, the 
quantity of fibrin in the blood appears to be small, but it experiences 
a marked increase at the period of puberty. Lehmann, in experiments 
upon himself, and Nasse, in experiments upon dogs, found that animal 
diet increased the proportion of fibrin above that which was found 
under a vegetable diet. 

1 Lehmann found in serum of the venous blood of a horse 11.428 parts of albumen per 
100; in arterial blood 9.217 parts per 100. The quantity of fibrin in the venous blood 
(jugular vein) was 5.384, that in the arterial blood was G.814. 



62 RED AND WHITE CORPUSCLES. 

Passing now to the morbid conditions in which the fibrin is found 
increased, we find, as a general law, that in all inflammatory diseases 
especially this is the case. In acute articular rheumatism, Andral re- 
cords in one case as high a proportion of fibrin as 10.2 per 1000, in 
several others it amounted to 6, 7, 8, or 9. In bronchitis (acute), the 
highest figure obtained was 9.3, in pneumonia, 10.5. The maximum in 
pleurisy was 5.8, in peritonitis, 7.2. The increase was nearly the same 
in one case of erysipelas, in which it amounted to 7.3, and in another of 
tonsillitis, in which it was 7.2. A very important circumstance, well 
shown by Andral's tables, is, that the effect of bleeding was not to 
diminish the fibrin ; in this respect, there was a marked contrast be- 
tween the fibrin and the red globules ; the latter sunk with each suc- 
cessive abstraction of blood, while the former most often rose, sometimes 
considerably. The following examples of this fact are very striking : — 



1st bleeding. 


2d. 


3d 


4th. 


5lh. 


&th. 


Acute Rheumatism 6.1 


7.2 


7.8 


10.2 


9 


7 


Pneumonia . . 7.1 


8.2 


9.0 


10.0 






Peritonitis . . 3.8 


4.7 


6.1 








Pleurisy . . 3.9 


5.8 











In tuberculization of the lungs the fibrin shows a decided increase, 
which, however, is most marked when intercurrent inflammation is set 
up in the part. In the crude state of the tubercles the mean.of the 
fibrin is about 4; when softening has commenced, it is about 4.5; when 
cavities have formed, it is from 5 to 5.b. The red particles steadily 
decrease from the first. In chlorotic persons the quantity of fibrin is 
maintained at its usual average, and is sometimes a little above; this 
circumstance, taken together with the great diminution of the globules, 
accounts for the formation of a buffy layer on the surface, which is not 
uncommon in such blood. 

Deficiency of fibrin is observed in very various morbid conditions. 
If we take as a certain indication the non-coagulated state of the blood 
(which perhaps, we are warranted in doing), it seems to be very defi- 
cient, generally, in all diseases proving fatal by asphyxia, or in which 
the respiration has been considerably interfered with for some time 
before death. Thus in cases of obstructive heart disease, the blood is 
very commonly in a fluid state, or very imperfectly coagulated, the 
coagula, such as they are, being very soft, and extremely friable. The 
same state is observed in cases of cyanosis, in which, owing to mixture 
of the venous and arterial blood, this fluid is never properly oxygenated. 
Excessive fatigue is said to prevent the blood from coagulating, but this 
has lately been contradicted by Mr. Gulliver, who found the blood co- 
agulated in a hunted stag, and in two hares run down by harriers. 
Various poisons seem to have the effect of preventing coagulation of the 
blood; among these are hydrocyanic acid, carbonic acid, sulphuretted 
and carburetted hydrogen. Andral states, that if a concentrated solu- 
tion of carbonate of soda be injected into a vein, the animal presents 
the symptoms of typhus, or scurvy (i. e. of a blood disease), and the 
blood is found fluid in the vessels. This statement is confirmed by Mr. 
Blake, and the same result proved to be produced by many other sub- 



RED AXD WHITE CORPUSCLES. 63 

stances: others, again, though of very analogous character, produced a 
contrary effect. For instance, when caustic soda, or carbonate of 
soda, was employed, the blood was coagulated imperfectly, or not at all, 
but when liquor potassae or its carbonate were used, the blood coagu- 
lated firmly. We have ourselves observed the formation of a buffy 
layer on the blood of an animal who had taken liquor potassae for several 
days, to the extent of disordering its health. Nitrate of potash, and 
many other neutral salts, did not at all impede the coagulation of the 
blood, while arsenious and oxalic acid, infusion of digitalis, and some 
metallic astringent salts, did so decidedly. We may infer from these 
observations, that it is not the alkalies, as such, nor the neutral salts, 
as such, which produce the effects that are usually ascribed to them 
upon the blood, but certain substances of particular qualities. Again, 
in adynamic fevers, we often find the blood remarkably fluid, so as to 
gravitate after death to all the depending parts, and during life pro- 
bably occasioning a tendency to hemorrhages, petechia, and vibices, 
which occasionally take place. The deficiency of fibrin in these cases 
is confirmed by analysis. Andral noticed some diminution of this ele- 
ment in the outset of continued fevers. It never increased, except on 
the supervention of an inflammation, and in the height of the disease 
sometimes sunk very low. In two cases, on the fifteenth day, it did 
not amount to more than 1. per 1000. A deficiency of fibrin might 
have been anticipated to exist in Purpura Hemorrhagica; and, indeed, 
sometimes this seems to be the case. Simon, in his Animal Chem- 
istry, gives two analyses; in one of which it is mentioned that there 
was no fibrin, in the other it only amounted to 0.905. Dr. Watson, 
speaking of this, or of the allied disease — scurvy — quotes a case, re- 
corded by Huxham, in which " neither of the portions of blood that had 
been drawn, separated into serum and crassamentum as usual, though 
it had stood many hours, but continued, as it were, half-coagulated, and 
of a bluish-livid color on the top. It was most easily divided on the 
slightest touch, and seemed a purulent sanies rather than blood, with 
a kind of sooty powder at bottom." Dr. Copland and others refer to 
similar cases. On the other hand, Dr. Budd testifies that, in some cases 
of scurvy, the coagulation takes place as in healthy blood; and in two 
cases lately examined by Dr. Parkes, it appears that the fibrin, at least, 
was not in any great degree diminished. 1 Dr. Graves also mentions 
a case in which, after each of three bleedings, there was formed a firm 
coagulum, with a buffy coat. The plethoric condition, characterized as 
we have seen by an excess in the quantity of red globules, and evidenc- 
ing a tendency to congestion and hemorrhage, is considered by Andral 
as generally associated with a deficient proportion of fibrin. He found in 
a strong, athletic man, who had symptoms of cerebral congestion, as 
low a figure of fibrin as 1.6; and remarks, that the minimum quantity 
occurred in those cases in which the symptoms of congestion were most 

1 In five analyses performed by Becquerel and Rodier, the general results were as fol- 
lows: The clot was always of good consistence, the density of the serum low, the water 
increased, the quantity of globules diminished as well as their ferruginous contents; the 
fibrin was never diminished — sometimes increased ; there was no increase of alkalinity or 
of salts ; the solids of the serum were notably diminished. 



64 RED AND WHITE CORPUSCLES. 

intense. In a female, who had been struck down senseless by an attack 
of apoplexy, the first bleeding showed the small proportion of 1.9 of 
fibrin, the globules being at 175.5. After three days, when conscious- 
ness had begun to return, she was bled again ; and now the fibrin 
amounted to 3.5, while the globules had diminished to 137.7. 

Alterations in the quality of the fibrin manifest themselves very 
clearly in the varying size and firmness of the coagulum, which forms 
in blood drawn from a vein, as well as in the peculiarities of structure 
which microscopic examination reveals. We will consider the general 
and the textural differences separately. To estimate aright the condi- 
tion of the coagulum of the blood, a full stream should be allowed to 
flow from a sufficient orifice into a deep vessel, which should be after- 
wards covered over, and should have been previously warmed. If 
drawn in a small, trickling stream, and received into a cold, shallow 
vessel, or if subsequently agitated, the coagulation is disturbed, and 
takes place either too rapidly, or forms, in the case of being agitated, 
irregular shreds. 

The coagulum, when formed, may be very large and firm, so as to 
offer considerable resistance when an attempt is made to divide it. 
This implies a fair proportion, or, perhaps, rather increased, of healthy 
fibrin, with a considerable amount of red corpuscles. I have been 
informed of the case of a plethoric female, whom it was necessary to 
bleed frequently, during her pregnancy. The coagulum was described 
to me as so firm " that it might have been kicked from one end of a 
room to the other." On the other hand, the coagulum may be large, 
but so lax as to be very easily divided, and, if handled, readily break- 
ing up. This implies either a deficient quantity of fibrin, or a de- 
fective contractile quality, or most commonly both. It may generally 
be taken as a positive sign that bleeding is not necessary, and that it 
will not be borne well. The coagulum, again, may be very firm, but 
considerably shrunken and contracted, manifesting this not only by its 
recession" from the sides of the vessel, but by the concavity of its upper 
surface; which at the same time is covered with a layer, more or less 
thick, of a light-yellow color. This layer is fibrin separated from the 
red corpuscles, and is commonly termed the "buffy coat." In this 
case the quantity of fibrin is much increased, and probably also its 
contractile quality, which occasions the reduced size of the clot, and 
the drawing in of the surface, or, as it is called, "the cupping." A 
buffy coat sometimes forms on the surface, of clots which are rather 
deficient in firmness; it is, however, but thin, rather transparent, and 
produces no " cupping." It is mostly seen in rather asthenic condi- 
tions of the system, and from its appearance the, blood which presents 
it is distinguished as " sizy." A very small, firm clot, with a more or 
less buffy surface, indicates a diminution of the red corpuscles, and at 
least a relative excess of fibrin. 

The following circumstances 1 are^favorable to the formation of the 

1 Dr. Todd and Mr. Bowman's "Physiological Anatomy," vol. ii. p. 295. It must be 
remarked, however, with regard to diminished density of the serum, that Mr. Gulliver 
has shown that in serum rendered thicker, heavier, and more viscid, by the addition of 
mucilage, the red corpuscles subsided not only more rapidly, but also more completely, 



RED AND WHITE CORPUSCLES. 65 

buffy coat : (1.) Slowness of coagulation, which gives the red corpus- 
cles more time to sink. (2.) Increased weight of the corpuscles, and 
their aggregation together into rouleaux. (3.) A diminution in the 
specific gravity of the serum. (4.) A great diminution in the propor- 
tionate quantity of the red corpuscles, or an increase in that of fibrin. 
None of these circumstances, however, seem to us to account fully for 
the phenomenon in question; and we are much inclined to believe with 
Dr. Alison, that there exists an absolute tendency to separation be- 
tween the fibrin and the corpuscles, somewhat, perhaps, of the nature 
of that which prevents the commixture of some dissimilar fluids. He 
remarks : " 1st. That the formation of the buffy coat, though no doubt 
favored or rendered more complete by slow coagulation, is often ob- 
served in cases where the coagulation is more rapid than usual; and 
the coloring matter is usually observed to retire from the surface of the 
fluid in such cases before any coagulation has commenced. 2d. The 
separation of the fibrin from the coloring matter in such cases takes 
place in films of blood, so thin as not to admit of a stratum of the one 
being laid above the other. They separate from each other laterally, 
and the films acquire a speckled or mottled appearance, equally charac- 
teristic of the state of the blood with the buffy coat itself." It does 
not seem necessary to assume that there is any actual repulsion of the 
red particles from the fibrin, the tendency to separation may simply 
depend on the increased attraction (which is manifest) of the respective 
parts of each element together. 

The differences in textured quality which fibrin often presents, have 
been admirably described by Rokitansky and Mr. Paget. We will 
follow the account given by the former, though it be somewhat in minute 
detail, as we may have occasion hereafter to refer to it. Taking strongly 
marked typical examples, he describes, 1st, the fibrin which is found in 
the bodies of healthy persons. This forms pretty compact and tough, 
moderately adhesive coagula of a whitish color, passing into yellow. 
They may be torn into membranous layers, and exhibit along the torn 
surface a delicate felting. Microscopic examination shows a clear 
(hyaline) membranous or flaky basis-substance, and upon it a thick felt 
of very fine, very elastic, black-bordered, branching fibres, quickly dis- 
solved by acetic acid, which project out free at the borders of the speci- 
men. Together with this there are seen on the preparation, appearing 
more evident after treatment with acetic acid, round, glistening nuclei, 
and along with these a few delicately-granulated, dull-looking, round, 
and oval nuclei, and similar cells of the- size of a pus-corpuscle. Of the 
same composition are certain soft, brawn-like coagula, termed Pseudo- 
fibrin, which Rokitansky regards as a very important transition-formation 
as regards healthy nutrition, between albumen and fibrin. 

The 2d variety of fibrin forms coagula much like those of the preced- 
ing, but of more adhesive quality. They include often in their substance 

than in serum, which was rendered thinner, lighter, and less viscid, by being mixed with 
a saline solution. Mr. Wharton Jones — from whom we have, in part, taken the above 
passage — believes that the viscid state of the liquori sanguinis promotes the subsidence 
of the red corpuscles, by increasing their natural tendency to aggregate together. 

5 



66 RED AND WHITE CORPUSCLES. 

notable quantities of serum. Under the microscope they are seen to 
consist of a flaky basis substance, which divides itself into fibres, either 
flat, or roundish, harsh, and stiff, or resembling those of organic muscle ; 
or the basis-substance may appear sometimes membranous, most deli- 
cately fibred, with a wavy crisping. On this basis there occur, together 
with elementary granules, numerous round black-bordered, sometimes 
also staff-shaped or fibre-like, elongated nuclei ; and besides these, espe- 
cially in the fluid which trickles out, there are granulated, dull-looking 
nuclei, and similar nucleated cells. This fibrin, with traces of the pre- 
ceding, is often combined with the other varieties. Rokitansky says 
of it, that it is often effused, as the result of morbid processes and of 
inflammation, and that it must be regarded as diseased, but to be dis- 
tinguished from the following varieties by the appellation of plastic or 
organizable. 

The coagula of the 3d kind of fibrin are distinguished by their opacity, 
by a dull-white color, verging on yellowish, or yellowish-green. They 
often contain, besides serum, red corpuscles also in considerable quantity, 
which indicate an increased capacity of coagulation, and more rapid 
occurrence of the same. They present in this case 
different shades of redness and opacity. Microscopi- 
cally examined, the coagulum is found to consist of a 
flaky or fibro-flaky basis mass, or of a dull, streaky 
membrane, each of which is rendered opaque by a great 
quantity of fine punctiform matter. Besides, there 
exist upon it, and together with it, in the serum, a 
great number of nuclear formations, and developed 
dull granulated nuclei, and similar more or less de- 
veloped cells. Often, the whole coagulum appears to 
consist of both the last-named elements, together with 
some punctiform substance. The nuclear formations 
in general show the ordinary indifference towards 
i n? U Z l&T /" a ^tic acid. This fibrin has less adhesive quality. 

healthy fibrin, from . ,» i ,. , i • i m-i 1 • i i 

exudation on perkar- .ribrin of the 4tn kind presents a still higher degree 
dium. it consists of an of the morbid condition of the preceding. The coagula 
homogeneous granular are in the highest degree opaque. When they contain 

basis, imbedding nu- , , , , £> , , ° x x , .«*' , 

merous corpuscles. no blood-globules they approach more manifestly to a 
greenish-yellow. Often, however, they contain large 
quantities of blood-globules, and are reddish-gray, or reddish-brown, 
which indicates rapid coagulation. More closely examined, they consist 
of a thick, finely-punctuated mass, of nucleus and cell-formations, com- 
porting themselves in various degrees more and more like the pus-cell 
and pus-nucleus, which are held together generally by a tenacious, amor- 
phous, uniting mass; no network of fibres exists, and no other fibre-for- 
mation. It has lost still more of the adhesive (soldering) quality. The 
3d and 4th forms Rokitansky denominates croupous. 

At this point the fibrin approaches close upon that existing in Pyaemia; 
it has the croupous constitution ; the nuclei and cells inclosed in the 
coagulum are true pus-nuclei and pus-cells. 

Though the above quotation is long, yet the great importance of the 
subject, and the value of the description given by so high an authority, 




KED AND WHITE CORPUSCLES. 67 

made us unwilling to omit or abbreviate it. Professor Paget, agreeing 
closely with Rokitansky, expresses the same facts more shortly and 
simply. His description refers, however, to fibrin, as it appears in ex- 
udations, while that of the German pathologist is expressly confined to 
the fibrinous coagula which are found within the vascular system. The 

Fte. 6. 




Softening fibrin from a vein clot. The dark points are minute oil drops. 

correspondence, however, between the fibrin in and out of the vessels is 
so close, that the characters of the one apply also to the other ; and we 
may, therefore, say, that all the varieties of the fibrin of the blood, as 
manifested by the condition of the coagula, depend upon the predomi- 
nance of one of two forms of structure. In healthy fibrin the fibrous 
structure greatly predominates, the whole mass fibrillates more or less 
perfectly, and the included corpuscles are comparatively few. This is 
Mr. Paget's fibrinous variety. Unhealthy fibrin, which tends to disin- 
tegration, consists of a granular mass, imbedding very numerous nuclei 
and cell-formations ; this is the corpuscular variety. These two corre- 
spond to Rokitansky's 1st and 4th varieties, and his 2d and 3d are only 
combinations of them in different proportions. 

We shall here briefly notice the metamorphoses which coagula of fibrin 
may undergo: (1.) A more or less perfect development of fibre may take 
place, in which the nuclei are chiefly concerned. (2.) The coagula may 
fall to pieces, and undergo a kind of dissolution into a pappy or pus-like 
fluid, or in some cases into a fluid which is really of the nature of pus. 
This change may befall coagula of healthy fibrin, in consequence of 
their being placed in conditions unfavorable to fibre-development, but is 
more particularly observed in the corpuscular varieties. It was shown 
by Mr. Gulliver, that the puriform fluid often found in vessels was really 
fibrin which had undergone softening ; and it was an important step to 
prove that such collections of pus-like matter were not the result of 
phlebitis; but in recognizing their non-inflammatory origin, perhaps, it 
has not been seen clearly how very similar, or even identical, they might 
be with certain forms of true pus. (3.) The fibrin may part with some 
of its natural moisture, and change into a resisting, stiff, dull, translu- 
cent, or also opaque, horny mass. In process of time it may become 
ossified (probably calcified). (4.) It may undergo fatty transformation, 
becoming converted into a mass of small, oily molecules or drops. (5.) 
It may gradually be dissolved and taken up again into the circulation. 
Rokitansky mentions as an instance of this the removal of fibrinous 
vegetations from the cardiac valves. 



68 ORGANIC CONSTITUENTS OF THE SERUM. 



ORGANIC CONSTITUENTS OF THE SERUM. 

Albumen is the principal organic constituent of the serum, in which 
it exists dissolved in water in the proportion of 63 to 72 parts per 1000 
of blood. The specific gravity of the serum is on an average 1028, and 
varies less than that of the entire blood. The serum is naturally of a 
light yellow color, which does not appear to depend on the presence of 
hsematine or of bile pigment, but to be special to this fluid. We have 
already expressed our dissent from the doctrine that the fibrin is the 
sole or chief material intended for the growth and nutrition of the tis- 
sues, and fully believe that the albumen is quite as much or more applied 
to this purpose. We have no means at present of ascertaining numerous 
qualitative variations which probably aifect the albumen of the serum. 
Indeed, we cannot but believe that its composition must be liable to con- 
tinual minute changes, as on the one hand nutritive material for various 
tissues is drawn off from it, and on the other, chyle, scarce yet raised 
to the blood-standard, and lymph, containing effete or semi-effete residua 
of nutrition, are poured into it. All such, however, to a certain extent, 
are clearly natural ; and were our powers of analysis greatly more refined, 
we should probably find that it was by the most gradual steps that physio- 
logical variations passed into morbid. 

The amount of albumen, according to Andral and Gavarret, is notably 
increased in various diseases ; but this excess does not appear to be 
characteristic of any. In acute rheumatism, an increase was found vary- 
ing from 4 to 24; in pneumonia, the highest increase was about 12; in 
pleurisy, the extraordinary amount of 34 in excess was once observed; 
and several other instances are mentioned of lower degree. Peritonitis, 
tonsillitis, and erysipelas, all furnish cases in which there was more or 
less considerable increase of the albumen. This is the case also in 
tubercular disease of the lungs, and in simple and continued fevers. 
Bleeding does not appear to influence the quantity of albumen in a very 
constant way; on the whole it tends to decrease it, and this seems to be 
especially the case in typhoid fever. In cases of cerebral congestion 
and of apoplexy, generally considered as examples of plethora, there 
was found, especially in the former, a very considerable increase in 
many cases of the albumen. This amounted once to 24.8 beyond the 
mean. In the latter there were several instances of marked diminution. 
Cases of chlorosis, in which the globules are so remarkably diminished, 
show rarely any diminution of albumen; and sometimes a considerable 
excess, amounting to 14 or 20 parts per 1000. 

Diminution of the albumen of the serum probably takes place in various 
diseases, attended with defective nutrition and wasting, but has been 
more particularly observed in renal dropsy. It appears as if the albu- 
men of the serum, being drained off in the urine, and in the dropsical 
efflux, there remains behind a less quantity in the blood. This idea is 
confirmed by the results of three successive analyses of Andral's, in the 
first of which there being much albumen in the urine, the serum contained 
only 57.9; in the second, the urine containing less albumen, the amount 
in the serum had increased to 66, in the third, the urine being no longer 



EXTRACTIVE MATTERS. 69 

albuminous, the quantity in the serum had returned to its normal figure, 
72. It is also in accordance with the circumstance noticed by Dr. Bright, 
and others, of low specific gravity of the serum in this disease. Still, 
this explanation does not accord with the general fact that dropsical 
effusions are more watery, and contain less albumen than the serum, 
which one would therefore expect to find of greater density in such cases. 
Probably the supply of such albumen, both from the chyle and lymph, 
is defective in quality and quantity. Becquerel and Rodier state, that 
in diseases of the heart the albumen of the serum varies but little as 
long as there is no dropsy; then it diminishes, and often considerably. 
In the disease called the rot, affecting sheep, which is characterized by 
the presences of numerous distomata (flukes) in the biliary ducts, M. 
Andral and his coadjutors found the albumen of the blood considerably 
diminished, as well as the red globules, while the water was greatly 
increased. Sheep are also subject to ordinary anaemia, i. e. to a defir 
ciency of red globules only in the blood, the albumen remaining at its 
normal amount; and it is very worthy of remark, that in these latter 
cases dropsy does not take place, while in sheep affected with the rot it 
is not uncommon. This seems to point out that when in cases of cachexia 
and debility serous infiltrations of the limbs occur, it is owing to a dimi- 
nution in the quantity of albumen in the blood. 



EXTRACTIVE MATTERS. 

Chemistry has as yet ascertained too little respecting these substances, 
even in the healthy condition, to make any conclusion possible regarding 
their variations in disease. Simon's division into water extract, proof 
spirit extract, and alcohol extract, is of no avail for physiology or 
pathology. As his eminent namesake remarks, what we want is a di- 
vision of these matters according to the organs or systems of organs 
that produce them. Still, the recognition of the existence of such mat- 
ters in the blood is important, as showing us the actual presence of 
principles that are effete, or tending to become so in this fluid, and 
reminding us how often ill health and malaise may depend on the 
formation of unnatural products of this kind, which come at length to 
be generated by an almost habitual vice of the system. 

According to Lehmann's estimate, the quantity of extractive matter 
in healthy blood is 0.25 to 0.42 per 100. Nasse found a larger pro- 
portion in the blood of children and of young animals than in that of 
adults. Arterial blood, according to Lehmann, contains more than 
venous blood in the proportion of 5.374 parts to 3.617. Portal vein 
blood of horses, five to ten hours after food, contained on an average 
7.422 parts; twenty-four hours after food the quantity amounted to 10; 
but it was always less than that existing in hepatic vein blood, which 
averaged above 18. The existence of a larger quantity of extractive 
matter in arterial than in venous blood, may perhaps be accounted for 
by the increased oxidation of some of the organic matters which takes 
place in and after the passage of the blood through the lungs. The 
larger amount in the blood of young growing creatures is in corre- 



70 OILY MATTER IN THE BLOOD. 

spondence with the greater activity of their circulation, and their nutritive 
processes generally. The excess in the hepatic vein above the portal 
blood indicates that an absorption of matter from the hepatic cells into 
the current traversing the lobules takes place. Sugar, we know, is 
conveyed into the blood from this source, and there is equal reason to 
believe that extractive matter may be. Though we cannot class liver- 
sugar, or glucose, altogether with extractive matter, as it is rather of 
the nature of a secretion, yet we cannot but notice the probable relation 
in which it stands to the disease called diabetes, and the ideas which this 
view suggests as to various diseases which appear to have their seat in 
the blood. It seems that one very important feature in diabetes is, that 
the sugar formed in the liver, and absorbed into the blood, is not de- 
composed, as it ought to be, into carbonic acid, but circulating in the 
blood, and arriving at the kidneys, stimulates them unnaturally, and so 
occasions the profuse diuresis which exhausts the system. So, various 
ill-defined extractive matters, intended to be decomposed and eliminated 
through the skin, or other channels, may fail to undergo their normal 
changes, and be, in consequence, more or less completely retained in 
the blood, which, circulating thus contaminated, becomes a source of 
mal-nutrition and disorder to various parts. "What more probable ac- 
count can be given of the origin of most skin diseases? Surely, in such 
an instance as this the value of a sound pathology is most manifest, if 
it be only to open our eyes to the absurdity of not a few of the ordinary 
remedial measures. Liebig has particularly described three substances 
which appear to belong to the class of extractive matter, creatin, crea- 
tinin, and inoshiic acid; the two former seem to be of the nature of 
alkaloids, the latter combines with bases as an acid. They are all 
nitrogenized substances, and are found in the watery extract of muscle; 
the two former are present in the urine, and are, therefore, doubtless 
effete. They do not seem to have been detected in the blood, but must 
of course have passed through it before being excreted with the urine. 
Creatin, Lehmann states, is analogous to Thein, an alkaloid, which in 
some trials has produced very severe nervous symptoms, even when 
taken in small doses. Many slight changes in creatin or the allied 
substances render them capable of producing any similar phenomena. 



OILY MATTER IN THE BLOOD. 

The quantity of oil existing in the blood cannot be estimated only 
from the amount contained in the serum, for it is present also in the 
red corpuscles, and in the fibrin. The quantity contained in the crassa- 
mentum, which is made up of these two components, is not much in- 
ferior to that in the serum. The serum of arterial blood contains less 
oily matter than that of venous. Lehmann gives 0.264 per cent, as 
the proportion in the first, 0.393 per cent, in the latter. 1 Chevreul 

1 Lehmann found in 100 parts of dried blood-corpuscles of the ox, 2.249 of oily matter : 
arterial blood-corpuscles contained 1.824 parts of oily matter per 100 thereof; venous 
blood 3.595 parts. 



OILY MATTER IN THE BLOOD. 



71 



states the quantity of oily matter in fibrin as amounting to 4 or 4J per 
cent. Lecame distinguishes a crystallizable and non-crystallizable oily 
matter in the blood, the former in the proportion of 1.20 to 2.10, the 
latter in that of 1 to 1.30 per 1000 parts of serum. Cholesterin and 
serolin are two crystalline fatty substances which have been found in 
blood; the former is of very common occurrence in exudations in 
various parts, and in some tumors; it forms the well-known rhomboid 
tablets, by which, when in a solid form, it is immediately recognized. 
The blood of females^ according to Becquerel, contains on an average 
more fatty matter than that of men. In both sexes, the quantity of 
cholesterin increases with advancing years, after the age of 40 or 50. 
It seems established, as was natural to expect, that the quantity of oily 
matter in the blood increases after taking food. A milky state of the 
serum had often been observed, but though it was generally supposed 
to depend on the admixture of chyle, this could hardly be said to have 
been proved until lately. Dr. Buchanan's experiments upon healthy 
persons show that the serum "becomes turbid about half an hour after 
taking food, the discoloration increases during several hours, attains 
its maximum in about six or eight (after a full meal), and then becomes 
gradually clearer till its limpidity is restored. The opaque serum is 
generally milk-white, sometimes cream-yellow, or yellowish brown, like 
thin oatmeal gruel ; or it merely loses its limpidity, and is like weak 
syrup. It always contains solid white granules, smaller than the blood- 
corpuscles, which are suspended in it, and which will rise in a white 



Fig. 7. 




Fig. 8. 



v£u»*.«" 






••V 







Cholesterin. 



Fat in Blood. 



cream to the surface, either spontaneously, or after the fluid has been 
saturated with common salt. The cream thus obtained is soluble in 
caustic potash, but insoluble in ether or alcohol, and is considered by 
Dr. R. D. Thomson as probably a protein compound." The micro- 
scopic appearance of milky serum, as I have observed it, has depended 
on the presence of a diffused finely divided matter, much resembling 
the molecular base of the chyle. Sometimes, however, distinct oil 
drops are observed. When we remember that the molecular opaque 
matter of the chyle is surely of oily nature, and find that the opacity 
of the serum, which occurs after a meal of food containing fat, is in 
part due to the presence of protein granules, we can hardly help enter- 
taining the idea which various other circumstances confirm, that the 
oily matter is actually converted into albumen. Should this ever be 



72 SALINE INGREDIENTS. 

proved to be the case, we should clearly see how in a lowered state of 
the vital powers, nutrition must be impaired, and how the failure of 
this, the first of the ascending nutritive processes, would be a prime 
cause of the degeneration of various tissues, or of the accumulation of 
adipose tissue, which are both signs of feeble general power. The 
general result of Becquerel and Rodier's very careful analysis of the 
blood in various diseases, with regard to the variations in the quantity 
of oil, is that almost from the outset of every acute .disease the amount 
is increased, and particularly that of the cholesterin. Diseases of the 
liver, Bright's disease, and tuberculosis have the same effect. 



SALINE INGREDIENTS. 

There remain for our consideration the various salts of the blood, and 
the water which holds them in solution. The amount of salts in the 
blood of man is somewhat greater than in the blood of woman ; that of 
the former contains, on an average, 8.8 per cent., that of the latter 8.1; 
in both sexes the variations compatible with health are considerable. 
The blood of adults contains more salts than that of children; arterial 
blood more than venous. The prolonged use of aliments containing 
much common salt is said to cause an increase in the proportion of the 
latter, and of the other salts generally. The following appear to be the 
principal saline combinations in the blood : Chloride of Sodium, and 
Potassium, Sulphate of Potash, Carbonate and Phosphate of Soda. Of 
the alterations which the salts undergo in different diseases we have not 
much knowledge. In malignant cholera, the excessive drain tells most 
on the fluid part of the blood, and hence that remaining in the vessels 
is thick and tarlike ; hence, also, the extraordinary, though temporary, 
effect of injecting saline solutions, which return to the blood the mate- 
rial effused from it, and revive all the functions that were wellnigh 
extinct. Doubtless, if the intestinal discharges could be arrested, the 
effect would be permanent, but as it is, their effect is soon exhausted. 
Henle assumes that in inflammation, when the flow of blood in a part is 
retarded, exudation of the more watery and saline parts of the liquor 
sanguinis takes place, so that that which remains in the vessels becomes 
inspissated, and producing endosmotic changes in the red corpuscles 
disposes them to adhere together. This view, however, is merely hypo- 
thetical. Vogel states that "the salts are increased in scurvy, and it 
is very probable that this change influences the condition of the fibrin, 
hindering its coagulability, and, perhaps, checking its formation ; that 
it affects the blood-corpuscles by withdrawing their water, rendering 
them granular, and collecting them in heaps; and that it thus plays an 
essential part in the disease itself." However, his statement has been 
contradicted rather than confirmed. In the cases of purpura examined 
by Dr. Parkes, which have been alluded to, the quantity of salts seems 
to have been below the average. In acute exanthemata, in dysenteric 
affections, in endemic agues, Lehmann mentions the proportion of the 
salts to be increased, as also in Bright's disease, in typhus, and in all 
kinds of dropsy and hydremia. In violent inflammation the salts are 
much diminished. 



WATEE. 73 



WATER. 



Lecame's estimate of the mean quantity of water in 1000 parts of 
blood is 790 ; he found more water in the blood of women than in that 
of men, more in the blood of children and of aged and debilitated per- 
sons than in that of vigorous adults, more in the lymphatic than in the 
sanguineous temperament. It is clear that the whole quantity of water 
is not contained in the serum, a certain proportion, which must vary 
with the specific gravity of the blood, is inclosed in the red corpuscles, 
and holds their coloring matter in solution. The serum of arterial blood 
and of portal vein blood is said by Lehmann to contain more water than 
that of venous blood generally. It is a very remarkable circumstance, 
and strongly indicative of wise provision, that it is very difficult to 
demonstrate by analysis an actual increase of the quantity of water in 
the blood after copious drinks have been taken. Denis and Schultz are 
at issue as to whether such an increase is detectable or not. This 
seems to show how exactly the vascular system is kept at a certain 
degree of tension, so that in proportion as absorption at one part takes 
place, excretion at another ensues correspondingly. The effect of bleed- 
ing and starving which was before noticed, of reducing the amount of 
globules, tells, of course, proportionally, in increasing the quantity of 
water; this can easily be ascertained, as it is in great measure relative; 
the merely positive increase is much more doubtful. Andral mentions 
a case of confirmed chlorosis, in which the water in the blood amounted 
to 867.9, an increase of nearly 78 parts per 1000. Lehmann states, 
that in the beginning of most diseases, especially acute ones, the blood 
is found more watery than natural, the serum, however, at the same time 
being richer in solid contents. He accounts for this, by supposing that 
the material which should have been applied to the formation of the 
globules, or which results from their decay, remains in the serum. 
During the first ten days of typhus, the first stage of scarlet fever, mea- 
sles, and cholera, this increase in the watery constituents of the blood 
does not appear to take place. 

The condition which is commonly called Anaemia should, it would 
seem, more properly be named Hydremia, as in most cases it is not so 
much a deficient quantity of blood which it is intended to describe as a 
defective quality. Doubtless, a person reduced greatly by phthisis, or 
any exhausting disease, is really in a state of anaemia; he has less blood 
than natural in his body, as well as too watery ; but a female suffering 
from consequences of amenorrhoea, with pale lips and face, is much 
more likely to be in a state of hydrsemia, the mass of blood not being 
diminished, but its red corpuscles replaced by water. 

Having examined the variations which the several constituent elements 
of the blood are liable to undergo, we next proceed to make a few re- 
marks on certain abnormal matters which are occasionally present in it. 
Carbonic acid gas, the product of respiration, i. e. of the conveyance of 
oxygen throughout every part of the frame, becomes, if it accumulates 
beyond a certain small amount in the blood, the cause of serious disorder 
and speedily of death. Various diseases of the thoracic viscera, or impedi- 



74 WATER. 

merits to the free action of the walls of the chest, prevent more or less 
the due oxygenation of the blood, which is indicated by the dusky hue 
of the complexion, the lividity of the lips, the sensation of oppression 
at the chest, and of dyspnoea. The larger the quantity of blood which 
is circulating in the vessels, and the more vigorous the state of health 
and the general activity of the functions, the greater must be the ac- 
cumulation of carbonic acid when any asphyxiating cause begins to 
operate, and the more severely will its effects be manifested. If, how- 
ever, the mass of blood be greatly diminished by exhausting drains, by 
diminution of food, and by non-development of its corpuscles, then the 
amount of respiratory action may be also greatly diminished without 
producing the symptoms above mentioned. Thus, if a person in health 
should suddenly be deprived of one-half or three-fourths of his breathing 
apparatus, he would quickly die, suffocated; but a patient in the last 
stage of phthisis, whose lungs are destroyed to the same extent, may 
continue to live on without experiencing any notable dyspnceal distress. 
In the same way, when, during violent exertion, a greatly increased 
quantity of carbonic acid is formed, the amount of oxygen introduced 
into the lungs requires to be increased in proportion, and hence the 
hurried and panting respiration. A hybernating animal scarcely breathes 
at all ; its animal heat is not above the temperature of the atmosphere, 
and all its functions are in abeyance; carbonic acid, therefore, is not 
formed, and the inhalation of oxygen is not necessary; life, reduced to 
this low ebb, continues in an atmosphere which would cause instant suf- 
focation if the animal were awake. Man does not hybernate, but it 
seems highly probable that the system must temporarily have been in 
a similar state in those cases in which life has been restored after pro- 
longed immersion for half an hour or more. In persons affected with 
the morbus coeruleus, when, from some malformation, the pulmonic and 
systematic circulations are no longer kept distinct, we have the best 
opportunities for observing the effect of an unnaturally venous condition 
of the blood. The following excellent description is given by Dr. Wil- 
liams: "Individuals thus affected are in a lower scale of animation. 
The slower processes of nutrition and secretion seem to go on pretty 
well, but the muscular power is low, slight exertions bring on symptoms 
of faintness, palpitation, suffocation, or insensibility, the animal heat is 
lower than natural, and there is greater suffering from the influence of 
cold. In short, all the powers of body and mind are slender, and are 
easily disordered by any circumstances which tax their activity. In the 

few that reach mature age there is no sexual passion The 

subjects of cyanosis are said to be very liable to hemorrhages, and 
when these occur spontaneously, or from accidental causes, it is very 
difficult to stop them. This must be ascribed to the deficiency of fibrin, 
which we have already found to occur where the changes of the blood 
by respiration are imperfect." 

In what way does accumulation of carbonic acid in the blood prove 
fatal to life ? We find, after death from asphyxia, the left side of the 
heart comparatively empty, and its cavities contracted, the right side 
gorged with blood, as well as the veins generally ; the lungs are also 
distended and gorged with dark blood. Now, it has been shown that 



WATER. 75 

the essential cause of the failure of the circulation is not paralysis of 
the heart, or of the brain, though these may have some influence, but 
arrest of the blood in the capillaries of the lungs. 

How this arrest is produced we have not sufficient positive information 
to enable us certainly to explain, but we see that it is a phenomenon of 
the same class as that congestion which has been mentioned as often 
occurring when the function of a part is suddenly put a stop to, or, as 
Dr. Carpenter expresses it generally, "the performance of the normal 
reaction between the blood and the surrounding medium (whether this 
be air, water, or solid organized tissue) is a condition necessary to the 
regular movement of the blood through the extreme vessels." The 
correctness of this position is almost demonstrated by the following ex- 
periment of Dr. Reid's: Having adapted an hsemadynamometer to a 
systemic artery of an animal, and obstructed its respiration, he found 
that when non-oxygenated blood was beginning to circulate, as shown 
by the commencing supervention of insensibility, the column of mercury 
in the tube was raised, indicating, of course, an increased resistance to 
the onward flow through the capillaries. 

In this instance the normal changes between the non-arterialized and 
the tissues could not take place, and, consequently, the blood could not 
freely pass through them. The converse of this experiment is presented 
to us in the effect of extreme cold on parts that are exposed to it. The 
functions of the part are abolished, the circulation languishes and at 
last ceases, the vessels remaining congested with venous blood, which is 
not carried onwards. Hence the blue, or livid color which the surface 
presents. In this case, the vital power of the tissues seems to be para- 
lyzed by the sedative influence of the cold, and as a consequence, their 
nutrition and circulation are also brought to a stand. The arrest of the 
pulmonary circulation in asphyxia seems very analogous to the foregoing 
instance; the normal changes in the lung tissue having ceased, the blood 
is no longer able to traverse its capillary plexus freely, but stagnates 
there, and congests the part. Thus far we simply class together a 
number of similar phenomena, and educe from the circumstances com- 
mon to them a kind of law, viz : that quoted from Dr. Carpenter. But 
lately, Dr. Draper has brought forward a view which is extremely plausible 
and beautiful, and appears to us likely to prove of the greatest value 
in physiology and pathology. It is founded on the statement, "that if 
two liquids communicate with one another in a capillary tube, or in a 
porous or parenchymatous structure, and have for that tube or structure 
different chemical affinities, movement will ensue, that liquid which has 
the most energetic affinity will move with the greatest velocity, and 
may even drive the other liquid entirely before it." The essential idea 
appears to be this, that the on-coming liquid is attracted, particle by 
particle, to various points of the tissue which it traverses, that the at- 
traction, having taken place, soon ceases, in consequence of an alteration 
being effected in the attracted fluid, and that then the particles of fluid, 
no longer retained or drawn to the part by attraction, are pushed on by 
fresh quantities of unaltered fluid, for which the tissue has attraction. 
Thus, in the systemic capillaries, the arterialized blood is attracted to 
the tissues, changed by the act of nutrition to venous, therewith loses 



76 WATEK. 

its capacity of being attracted, and is driven on by more arterial blood, 
coming up within the range of the tissue's attraction. In the same way 
we may conceive an attraction to subsist between the venous blood and 
the air in the cells of the lung, which will, of course, cease as soon as 
the change from venous to arterial blood has been accomplished. The 
effect of this nutrition force, a term which we prefer to Dr. Carpenter's 
"capillary force," is, evidently, to promote remarkably the free transit 
of the blood through a part, and there can be no doubt that the arrest 
or abolition of this force must tend materially to obstruct the circulation. 
Hence, in asphyxia, the attraction probably continuing some time, but 
the normal changes which liberate each particle from it not taking place, 
the blood continually arrives and stagnates in the pulmonary capillaries. 
We have dwelt the longer on this subject, because it appears to us of so 
much importance to recognize the principle that the nutrition of a part 
influences so materially the circulation of blood through it, and because 
we may often have occasion to refer to the view here enunciated. The 
poisonous influence of carbonic acid is well shown by the following com- 
parative experiment of Rolando. He tied one of the bronchi in a tortoise, 
and found that the animal was not materially injured thereby; but when, 
instead of merely cutting off the access of air, he furnished a supply of 
carbonic acid to that lung, the other still receiving air, the animal died 
in a few hours. 

When the action of the kidneys is arrested, or seriously interfered 
•with in any way, their secretion products are no longer carried out of 
the system, but remain in and contaminate the blood. The effects pro- 
duced by the blood thus poisoned are somewhat different, according as 
the secretion is more or less suddenly and completely suppressed. When 
the suppression occurs suddenly, the acute form of uraemia, as it is 
called, manifests itself. Frerichs describes three varieties of this. In 
the first, after some pain of the head, giddiness, or vomiting, the patient 
soon sinks into deep stupor, from which in no long while he cannot be 
aroused. In the second, epileptic convulsions suddenly appear, affecting 
the whole muscular system, and returning after occasional intermissions. 
The consciousness may remain unaffected. In the third form, both 
convulsions and coma occur. Such cases constitute the disease which 
received a separate name, as ischuria renalis, but they probably belong 
to the same class as the acute anasarca, which occurs sometimes spon- 
taneously, or after scarlet or typhus fever, the anatomical characteristic 
of which is great sanguine engorgement of the kidney. Uraemia, in its 
chronic form, appears at the close of Bright's disease very frequently. 
Frerichs describes it as coming on gradually and unperceived, occasion- 
ing dull headache, or confused sensation, impairing the mental and 
bodily faculties, and producing some dulness and drowsiness. These 
symptoms may remit if the urinary secretion increases, or they may 
progress, and become more intense, the drowsiness deepening into stupor 
and coma. Vomiting is a frequent symptom in uraemia, and sometimes 
amaurosis, or disturbance of the hearing, is observed. Diarrhoea some- 
times takes place, and seems to avert the dangerous consequences of 
uraemia; it was a prominent symptom in the animals whose kidneys 
were extirpated by Prevost and Dumas, and in those similarly treated 



WATER. 77 

by Bernard and Barreswill ; in the latter, it was particularly observed 
that large quantities of ammoniacal fluid were poured out by the mucous 
membrane of the stomach and intestinal canal ; while these continued, 
the cerebral functions were impaired, but as soon as they ceased, the 
symptoms of intoxication commenced. Inflammations of the serous mem- 
branes, especially the pleura and pericardium, are very commonly pro- 
duced by ursemic poisoning in a less severe form. Cases of pericarditis 
of renal origin are nearly as frequent as those of rheumatic. The term 
uraemia seems to imply that the poisoning of the blood depends on the 
presence of urea, and such has long been the general belief, but numerous 
experiments and observations of late have done much to invalidate it. 
The quantity of urea in the blood, and the intensity of the symptoms, 
bear no proportion to each other ; there may be much urea in the blood 
and no symptoms, and severe symptoms with little or no urea in the 
blood. Dr. Rees, observing this, concluded that a watery state of the 
blood was the cause of the symptoms. Dr. Todd, Vauquelin, and others, 
have injected urea into the veins of animals, or given it by the mouth, 
without producing any other effect than increasing very greatly the flow 
of urine. Still more, Frerichs has repeatedly injected human urine into 
the blood of animals without producing any ill effects. It seems clear 
then that it is not urea, nor any other constituents of the urine, that 
produce, by their presence in the blood, the symptoms of poisoning. It 
may be, however, some of their decomposition-products; and Frerichs 
states that he has proved it to be the carbonate of ammonia, which is 
well known to result from altered urea. He has repeatedly demon- 
strated the presence of ammonia in the air expired by the sick, and by 
animals into whose veins urea had been injected after extirpation of the 
kidneys. Carbonate of ammonia, he says, can always be detected in the 
blood whenever uraemic symptoms exist, as well as usually traces of un- 
destroyed urea. The two following experiments certainly go far to 
establish French's theory of ursemic intoxication. When a solution of 
urea is injected into the veins of animals from whom the kidneys have 
been removed, no symptoms take place for some time ; but after one 
hour and a quarter to eight hours vomiting commences, and convulsions, 
or sopor, and coma begin to appear at the same time that ammonia can 
be detected in the air expired. After death, ammonia in large quantity 
was found in the blood. " The brain and its membranes were normal 
in appearance, and the quantity of fluid in the ventricles was not in- 
creased." In the second experiment, a solution of carbonate of ammonia 
was injected into the veins of animals. Convulsions often very violent 
in character instantly ensued, and stupor quickly supervened. The 
respiration was difficult, the expired breath was loaded with ammonia, 
and vomiting of bilious matter occurred. While the stupor lasted am- 
monia continued to be expired, but when this disappeared the animals 
recovered their senses. What is the exact cause of the inflammations 
of the serous membranes, which often prove fatal in renal degenerations, 
does not seem made out ; it does not appear to be the presence of urea 
in the blood, as we have no evidence that this is capable of producing 
such effects. Frerichs thinks that the impoverished state of the blood 
is an adequate cause, but in this we can hardly agree. While speaking 



78 - WATER. 

of urea as a substance abnormally present in tbe blood, it must not be 
left unnoticed, that it is only its presence in anything like considerable 
quantity that is abnormal, since it has been clearly proved that a minute 
quantity exists in perfectly healthy blood of men and animals. The 
same is the case "with another constituent of the urine, viz : uric acid, 
which exists naturally in small proportion in healthy blood, but accu- 
mulates therein from defect in the excreting functions of the kidney 
just before an attack of acute gout, and also in chronic. As it is defi- 
cient in the urine, Dr. Garrod's conclusion seems just, that the chalk- 
like deposits appear to depend on an action in and round the joints 
vicarious of the uric acid excreting function of the kidneys. The well- 
known effects of the presence of this gouty matter (uric acid) in the 
blood, as the malaise and ill health which precede the attack, the 
inflammation produced by its localization, and the occasional serious 
result of its transfer to more vital parts, illustrate exceedingly well the 
disturbing action of an excretory substance retained in the blood. 

Lactic acid was believed by Dr. Prout to be the materies morbi in 
rheumatism ; he states that it is thrown off in immense quantities from 
the skin during the perspiration. Absolute proof of this, perhaps, is 
wanting, but as we know that this acid can be obtained from muscular 
fibre, and exists in the gastric, cutaneous, and urinary secretions, it is 
very probable that this is the case. In health, lactic acid is, most pro- 
bably, rapidly disintegrated in the blood by oxidation, being converted 
into carbonic acid and water; in rheumatic and other diseases we may 
suppose this process to be interrupted, and that the acid, therefore, or 
its combinations, accumulates in the blood, and is thrown out by an 
excessive action of the perspiratory glands. This view is confirmed by 
the obstinate nature of many cases of rheumatism, and their great tend- 
ency to recur, indicating a deep-seated defect in some of the processes 
of organic life. It is also confirmed by the good effects of eliminative 
treatment succeeded by tonics, the object of which is to carry off the 
morbid matter that vexes the system, and afterwards to invigorate the 
general powers, so that the organic functions may be more properly per- 
formed. 1 Rheumatism is so manifestly akin to gout, that this conviction 
is a further argument for believing that the former depends, like the 
latter, on a materies morbi. 

Whether Bile, when present in the blood, is the cause of disorders, 
we do not certainly know. Its gradual disappearance as it passes down 
the intestinal canal, is considered by Liebig as a proof that it is absorbed, 
but Lehmann is unable to find any trace of it in the blood of the portal 
vein. It may, therefore, be decomposed and not absorbed. Biliary 
pigment is often present in the blood in considerable quantity without 
occasioning much disturbance, but we cannot speak so positively with 
regard to the biliary acids. In that terrible affection of the liver called 
by Rokitansky acute yellow atrophy, in which the cells of the organ are 
completely destroyed, and the whole tissue deluged with yellow pigment, 
we are quite ignorant of the exciting cause of the convulsions and coma 

1 This view is the same as that most ably maintained by Dr. Fuller, in his truly valuable 
work on Rheumatism. 



WATEK. 79 

by •which the disease commonly proves fatal. No chemical examination 
that we know of has yet been made of the blood in this disease, and all 
that can be said is, that it seems most probable that the poisonous matter 
which produces the cerebral symptoms is none of the constituents of the 
bile, since both of them, the pigment and the cholic acid, have been 
found in the blood when none of the symptoms of cerebral disturbance 
were present. It may be, perhaps, a decomposition-product of the 
organic biliary acids. However, though we cannot point out what the 
materies morbi in this case is, there is no doubt that the phenomena in 
this affection are owing to the presence of some abnormal matter circu- 
lating with the blood. 

In that state of system which Dr. Prout has distinguished by the name 
of the oxalic acid diathesis, there seems good reason to believe that 
oxalic acid, or some of its salts, must be present in the blood, and be the 
exciting cause of the various symptoms. It is very probable that imper- 
fect digestion often gives rise to the formation of this acid, but in other 
instances we are inclined to believe that its origin lies deeper, in a mal- 
performance of some of the secondary assimilating processes. In not a 
few cases, the presence of this abnormal matter in the blood is betrayed 
by scarce anything else than the existence of characteristic octohedral 
crystals in the urine; but in others, and, perhaps, the majority, it seems 
impossible not to recognize a connection between the state of the blood 
evidenced by the urinary deposit and the peculiar nervous erethism and 
sensibility which exist. The circumstance mentioned by Dr. Prout, that 
those who have this diathesis are very liable to skin diseases, and affec- 
tions of the nature of boils and carbuncles, also points to the presence 
of a materies morbi circulating in the blood. It is very conceivable, that 
a small quantity of this acid formed in, or introduced into, the blood, 
and constantly drained off by the urine, may give rise to no symptoms, 
but, that the presence of a larger quantity, and more especially its non- 
excretion by the kidneys, may cause great disturbance. This is in ac- 
cordance with Dr. Walshe's experience, who remarks: "Observation con- 
tinues to exhibit to us the frequency of a deposit of oxalate of lime 
crystals, at the period of convalescence of acute diseases ; so much so 
that we regard their sudden appearance in an acute disease as a sign of 
that fortunate change. This deposit is of temporary (say a few days') 
duration, and not to be confounded with the more or less permanent 
condition appertaining to a peculiar diathesis." 1 

The above-mentioned substances, abnormally present in the blood, and 
producing disease, are tolerably well defined, but there are a multitude 
of others of whose nature we are totally ignorant, and which quite escape 
our means of observation. The principal of them are the infectious prin- 
ciples of the so-called Exanthematous diseases, including continued fever; 
syphilis belongs to the same category, and various cutaneous disorders, 
especially the squamous and vesicular. Variola, and its modification 
vaccinia, are the only instances in which we can at all pretend actually 

1 We have observed in a specimen of blood drawn from a man suffering under an attack 
of hemiplegia, a number of large octohedral crystals exactly similar to those of the urinary 
deposits. 



80 WATER. 

to exhibit the materies morbi, and to transfer it from one system to 
another; even in these cases, the visible fluid is but the vehicle of the 
poison, for that is aeriform, and capable of being received through the 
channel of the lungs. The venom of deadly snakes, perhaps, may be 
an instance in which the matter inducing the morbid alterations in the 
blood of the bitten person is manifest and palpable, but even here we 
have no knowledge what the substance is which produces the septic 
effects. In the case, however, of deleterious gases, and of most poisons, 
the toxic agent is clearly known, and we can form some idea of its mode 
of operation. It would be quite beyond our province to attempt any 
detail of the various poisons and the effects they produce; we can only 
observe that they are all referable with tolerable accuracy to three heads, 
or to two of these combined, viz: (1) poisons which act as irritants, pro- 
ducing more or less irritation and inflammation of various organs; (2) 
poisons which act as sedatives, causing paralysis, more or less immediate 
and complete, of the nervous system; (3) septic poisons, which seem to 
annihilate the vital power, and induce rapid putrefaction of all the 
organic fluids and solids. 

With regard to the action of poisons there are two fundamental ideas 
which it seems desirable briefly to refer to. One is, that when a minute 
portion of virus is introduced into the system, it appears to multiply 
itself immensely, as if it possessed the power of transforming healthy 
matter into its own noxious nature. Such a multiplication must take 
place when an unprotected person is inoculated with the matter of variola, 
the minute quantity of virus introduced reproduces similar properties in 
the contents of the numberless pustules which are formed all over the 
surface. The same is, doubtless, the case with all infectious diseases, 
and with syphilis. In the latter instance, it seems worthy of considera- 
tion whether the great difficulty of eradicating the taint from the system 
may not depend on the less degree of constitutional disturbance which 
the virus occasions, and its inferior tendency to eliminate itself by under- 
going certain transformative changes. May not the action of mercury 
be chiefly to promote these changes, and so render the materies morbi 
more ready to be eliminated; this seems both consonant with what we 
know of its action, and supported by its superiority over other drugs 
which are capable of producing much more powerful excretory action. 
Were the action of mercury merely that of increasing the action of the 
several emunctories, syphilis ought to be curable as well by sweating, 
purging, and diuresis, which is not the case. On this view also we per- 
ceive the reasonableness of not salivating a patient profusely, but main- 
taining for a good while a mild but efficient alterative action. The con- 
ception now mentioned applies more particularly to certain irritant poisons, 
the second to those that are termed septic. When spongy platinum is 
placed in a mixture of oxygen and hydrogen gases, they quickly unite 
together and form water, the platinum itself undergoing no change. 
This is an example of what Berzelius named "catalytic action;" there 
are many similar known instances, and it is very probable that actions 
of this kind are by no means infrequent in the animal system. The 
solution of the food in stomach digestion is, probably, in part, dependent 
on a catalytic action, or one of a somewhat similar kind, in which the 



81 

peculiar organic matter called pepsin disposes the alimentary ingesta to 
undergo solution in the gastric acids. A minute quantity of the change- 
inducing substance is sufficient to cause the action to commence, and so 
it appears a minute quantity of virus is sufficient to induce septic changes 
in the blood with which it is mingled. The history of cases of death 
from the bite of venomous reptiles, of the most malignant fevers, espe- 
cially scarlatina, and of the effects of the matter of glanders, shows that 
the essential and primary action of these poisons is to lower extremely 
the vital powers, and induce putrefactive changes in the organic fluids. 
If this action be not utterly overwhelming, the system takes alarm, and 
manifests resistance and reaction by setting up the inflammatory pro- 
cess ; but this, it is quite clear, is only the secondary result of the poison, 
and not essential. In some constitutions the vital power is weak, and 
is seriously affected by comparatively slight agencies ; thus, it is recorded 
that very alarming symptoms have been produced by the sting of a bee 
and of a wasp. The state of the blood when affected by septic poisons 
will be hereafter described under the head of Necraemia, an appropriate 
name which has been assigned to this state by Dr. Williams. Pyaemia 
is the name given to a certain state of the blood somewhat akin to the 
foregoing, in which an unnatural matter, that of pus, is present and cir- 
culates with it. The matter itself will be described hereafter when we 
speak of the products of inflammation, and the condition will be con- 
sidered as a general disease of the blood. 



ANEMIA, SPANJEMIA. 

There can be little doubt that by excessive hemorrhage, or exhaust- 
ing discharges, the whole mass of circulating fluid in the vascular sys- 
tem can be considerably reduced ; that is to say, the result of such losses 
is not only to impoverish the quality (as we know it does), but to dimi- 
nish the quantity of the whole mass of blood. The term anaemia, signi- 
fying absence or deficiency of blood, is therefore correct, though if it 
were not so commonly received and employed, one might wish to sub- 
stitute the term oligsemia. Spansemia is the name proposed by Dr. 
Franz Simon to express a deteriorated quality of the blood {anavos, poor) ; 
it almost always accompanies the state of oligsemia, or anaemia; both 
may, we are inclined to think, exist not unfrequently as the sole con- 
dition itself, the blood being of normal quantity, but impaired quality. 
We will here recapitulate shortly the changes which have been before 
detailed in the several constituents of anaemic and spanaemic blood. 
(1.) The red corpuscles are remarkably diminished, 127 being the 
average per 1000; they have been known to sink as low as 27; they 
also appear to contain less haematine, being somewhat paler than those 
of healthy blood. (2.) The amount of white corpuscles does not appear 
to be altered; in some of our examinations they have been found as 
numerous as in healthy blood. (3.) The fibrin is quite unaffected; it 
was never found below the normal mean, and in cases where inflamma- 
tion of some organ was present, its quantity was notably increased. 
(4.) The solids of the serum have not been found specially altered. 
6 



82 ANJEMIA, SPAN^EMIA. 



(5.) The quantity of water is more or less increased in proportion to 
the diminution of the globules ; in the case above mentioned, where the 
globules were only 27 per 1000, the water was 886. 

The causes which produce anaemia and spanaemia are : (1.) Losses of 
blood, whether natural or artificial, the red globules being thus dimi- 
nished, their place is supplied in great degree only by the absorption of 
water. (2.) Profuse discharges of watery, mucous, or albuminous fluids, 
such as occur in aggravated leucorrhoea, diarrhoea, or in cases of cauli^ 
flower excrescence. In these, it seems as if the blood-globules were 
melted down to supply the profuse drain ; probably they perish, or are 
not reproduced from want of a proper nutrient fluid. (3.) Insufficient 
food ; the effect of a greatly improved diet in increasing the amount of 
red corpuscles was very apparent in a case under our observation, in 
which iron had been previously administered, with some, but not marked 
benefit ; while on the improvement of the diet the amelioration was rapid. 
Too often, no doubt, this cause operates powerfully in inducing the 
anaemia so common among young females of the lower classes. (4.) De- 
privation of fresh air and light ; the effect of this can scarcely be over- 
estimated. Even the best food will not be converted into healthy blood 
if light and air are withheld ; while a coarse and insufficient nutriment 
will not prevent a person from having a ruddy color, if he be much in 
the open air. Of this we have frequent instances among our laboring 
population. (5.) An unhealthy crasis of the blood, in consequence of 
which the existing blood-globules are imperfectly nourished, and the 
development of new ones is hindered. Such is the cause of the anaemia 
in persons suffering from degeneration of the kidneys, from lead 
cachexia, the ,cancerous diathesis, perhaps the tubercular, and in some 
chlorotic cases. There can be no question that in many cases, as is 
well described by Dr. Williams, the anaemia is not the cause but the 
result of the amenorrhoea. The suppression of the natural evacuation 
leaves the blood in an unpurified state, which is unfavorable to the 
development of healthy haematine. In the same way rheumatism may 
prove a cause of anaemia, and in several of Andral's cases, the globules 
at the first bleeding were found not to be below the ordinary average. 
Mental anxiety may probably also be considered as a cause of this kind. 

The symptoms of anaemia and spanaemia depend immediately on the 
impoverished condition of the blood. The face is pale or sallow, accord- 
ing to the natural tint of the skin ; the prolabia are blanched from their 
cherry red ; even the tongue presents unnatural pallor. The con- 
junctivae, it may be remarked, are clear, which should always be ob- 
served, and may prevent the error that has been sometimes committed 
of mistaking the sallow tinge of the complexion for a bilious, and direct- 
ing the treatment accordingly. In some cases there is a show of patchy 
redness on the cheeks, but this is very different from the natural diffused 
redness which is seated in the capillary plexus, and rather seems to 
depend on the congestion of some superficial thin-coated veins, which 
naturally would not be seen. 

To the ear the impoverished condition of blood announces itself by 
certain abnormal noises in different parts of the vascular system. 
These, the so-called inorganic murmurs, as distinguished from those 



ANAEMIA, SPAN^EMIA. 83 

which depend on structural alterations, are commonly heard over the 
base of the heart, and at the root of the neck on either side. The first 
are produced at the origin of the aorta, or of the pulmonary artery, 
and are probably, as Dr. Williams believes, of the nature of ripples, the 
natural inequalities of the surface over which the current passes being 
sufficient to occasion in its dilute and diminished condition " vibrations 
and sonorous gushes," which would not occur in a fluid of greater 
density. The latter are generally believed, and no doubt correctly, to 
be seated in the larger veins ; they probably depend, partly on the 
vibration of the valves, partly on local compression, which causes a 
sonorous gush, where the fluid passes from the narrowed channel into 
the wider. 1 It must not, however, be omitted, that these murmurs are 
not absolutely a sign of anaemia; they are also audible, though with less 
intensity, in many young persons, and in some aged, who present no 
trace of this condition. As the impoverished blood runs the round of 
the circulation, all the parts that are dependent upon it for the main- 
tenance of their several powers become more or less injuriously affected. 
Those in which the process of decay and repair is most active, of course 
will suffer earliest and most. Accordingly, we find the muscular and 
nervous system the seat of most marked disorder. 

The heart, illustrating the converse of the aphorism, that "repose is 
the revelation of power," betrays its feebleness by the weak and thready 
state of the radial pulse, by the coldness of the surface and extremities, 
and by the sudden, brief, often palpitating or irregular character of its 
contractions. The least bodily or mental excitement is sufficient to 
cause violent palpitation, as if the organ were conscious of its weakness, 
and strove by the frequency of its action to compensate for the imper- 
fection of it. Sometimes, even without any excitement, the heart beats 
very forcibly, so much so, that an inexperienced observer might easily 
be led to suppose the organ hypertrophied ; but the sharp knocking 
character of the impulse is extremely distinct from the steady, strong, 
heaving swell of the real hypertrophy. Such continued increased 
action of the heart is as much due to an abnormal condition of the 
nervous as of the muscular system. The contractile power of the 
muscles generally is impaired, and a slight effort induces fatigue, or 
even faintness ; there is no capacity for any sustained exertion ; the 
bowels are often costive, apparently from want of tone in the muscular 
coat, which should propel the contents onward. The disorder of the 
nervous system is especially manifested by the increase or perversion of 
the natural sensibility. All causes of pain or uneasiness produce more 
than their usual effects ; a variety of anomalous distressing sensations 
are complained of, some of which are fugitive, or affect one part after 
another, but one at least locates itself with remarkable constancy in the 
left side or hypochondrium. It is difficult to say what is the real state 
of the morbid action that occasions these pains, whether it be in the 
central organs, the pain, according to a well-known law, being referred 
to the peripheral termination of the fibre, or as we are rather inclined 
to think, located in the nerves themselves, their delicate substance being 

1 Kivisch, however, earnestly contends for the arterial seat of spansemic murmurs. 



84: ANEMIA, SPANJ3MIA. 

in some degree disordered by the imperfect nutrition afforded by the 
impoverished blood. The sympathetic nervous system is also affected; 
the appetite is lost or sometimes strangely perverted, so that the patient 
will eat chalk, cinders, sealing-wax, &c. ; the stomach becomes irritable, 
and often cannot tolerate substantial food or tonic remedies, or, together 
with the intestines, secretes enormous quantities of gas. The nerves of 
the kidneys are often so affected, that the secretion of the organs is 
materially modified for a time, and a copious flow of almost aqueous 
urine takes place. Or, those of the bladder may be affected, and there 
may be either inability (supposed) to void the urine, or to retain it. 
The nerves of special sense may be affected, and intolerance of light and 
sound, flashes before the eyes, and noises in the ears, may be present. 
The intensified action of the heart has been already referred to. All 
these symptoms indicate that condition already described, in which the 
sensibility of the incident nerves themselves appears increased, and the 
receptive and reactive power of the nervous centres also. The nervous 
system in the anemic condition may be likened to a spring, which origi- 
nally was of a certain strength, requiring a certain impressing, and 
reacting with a corresponding force, but having become much weakened, 
is bent by a much less force, and reacts also with much less. Mobility 
and debility may be said briefly to be the chief characteristics of the 
nervous actions in the anaemiated. Dr. Williams, remarking on the 
nervous excitement of anaemia, and contrasting the (apparent) increase 
of this function with the failure of others, is inclined to account for it 
by the circumstance, that the encephalic bloodvessels, being less 
exposed to atmospheric pressure than the vessels of other parts, are apt 
to contain relatively more blood then, under the circumstances, than 
they should. This undue supply of blood, if the heart's action be 
hurried, or excitement be otherwise induced, may produce an erethism 
of the nervous centres, with the symptoms above mentioned ; or if the 
heart's action be languid, it will stagnate, and occasion headache, 
relieved by the recumbent posture, drowsiness, impaired mental faculties, 
or even, in extreme cases, coma. The stagnation probably takes place 
chiefly in the large veins and sinuses. We confess that we doubt the 
correctness of Dr. Williams's fundamental assumption, that the ence- 
phalic bloodvessels, in the anemic condition, contain more than their 
due share of blood. We have seen so often in autopsies the most 
marked pallor of the membranes, and emptiness of the bloodvessels, 
except the large venous trunks, that we cannot think the peculiar posi- 
tion of the vessels exempts them at all from being in a like condition, 
as to fulness or emptiness, with those in other parts of the body. In 
fact, the sub-arachnoid fluid is to them what the atmospheric pressure 
is to others; and hence an anemic brain is commonly a "wet" one — 
i. e. the sub-arachnoid fluid is increased. The real cause, we believe, 
of the nervous excitement which is apt to occur, is the altered condition 
of the nervous matter, both white and gray, in consequence of its defect- 
ive nutrition. Hence (like the weakened spring) it becomes so suscept- 
ible, that it is injuriously affected by even natural and healthy excitants. 
Perhaps, also, deficient tonicity of the vessels may contribute, in part, 
to increase the cerebral excitement. This would allow of an increased 



ANEMIA, SPANJEMIA. 85 

flow of blood to the brain, and also make it be attended with throbbing, 
on account of the flaccid state of the conducting pipes. 

"Weak digestion, or apepsia, is a very frequent accompaniment of 
anaemia, and is doubtless occasioned by the debilitated state of the 
muscular coat of the stomach, as well as by the deficiency of gastric 
juice, which the follicles are unable to furnish, in consequence of their 
own nutrient supply being defective. Hence arises a further cause, 
which continues and aggravates the anaemia. Healthy chyle cannot, 
of course, be formed to renovate the blood, if the digestive function is 
seriously impaired. 

Some of the results of anaemia may next be noticed. Several in- 
stances have occurred in which the nutrition of the heart had suffered 
so much, and the organ become so debilitated, that sudden and fatal 
syncope was the result. The possibility of this should always be borne 
in mind in treating a case of severe anaemia, and the patient should be 
enjoined to avoid sudden efforts, and to remain as quiet as possible until 
some degree of strength and tone is restored. It is a question of much 
interest, but as yet we believe not determined, whether the increased 
action of the heart above described ever produces structural change. 
It would be thought likely that a weakened hollow organ, contracting 
repeatedly for a long time on a mass of blood poured into it, would be 
apt to yield somewhat to the outward pressure or resistance of the fluid, 
and thus become dilated; but it does not seem to have been shown that 
this actually takes place. Some degree of anasarcous swelling of the 
feet and ankles is not uncommon. When this occurs, we may take it as 
a sign, on Andral's authority, that the albumen of the serum is dimi- 
nished. Asthenia may advance to such a degree, that it proves fatal by 
a gradual failure of the vital pow T ers, like the sinking at the close of 
diseases of exhaustion. The impoverishment of the blood may probably 
be the determining cause of the appearance of tuberculous or other 
cachetic diseases. Dr. Williams describes a fatal termination to anaemia, 
which we have not actually witnessed, although we have seen more 
than one occurrence so closely similar, that we are convinced of the 
correctness of his account. The importance of the subject makes us un- 
willing to abridge Dr. Williams's description: "A young female becomes 
anaemic; and after exhibiting various symptoms of feeble general cir- 
culation, with headache, drowsiness, and impaired sensorial functions, 
suddenly becomes worse; passes into a state of stupor, with dilated 
pupils, sometimes varied by slight manifestations of delirium, throbbing 
of the carotids, and partial heat of the head, and dies comatose. On 
opening the head, a small quantity of serum is found under the arach- 
noid, and in the ventricles, sometimes with a little lymph (in one case 
there was none). The vascularity of the membranes is remarkable, 
but the vessels most distended are the veins, and in the larger of these, 
and in the longitudinal sinus, there is a firm coagulum. In parts, 
especially at the torcular Herophili, this coagulum blocks the whole 
sinus, and exhibits a separation of fibrin, portions of which are soft- 
ened down into that opaque purilaginous matter, which was long 
mistaken for pus, but which Mr. Gulliver has shown to be a mere disin- 
tegration of the fibrin, which mere stagnation in a warm tempera- 
ture may effect. These have been taken for cases of meningitis. No 



86 

doubt inflammation may supervene in them occasionally; but in two 
cases that have fallen under my notice, there was no adhesion of the 
arachnoid, nor deposit upon it, nor any other unequivocal mark of in- 
flammatory action; yet the fibrinous and bloody concretions in the veins 
and sinuses were most remarkable for their size and firmness." 

In the cases of similar nature which have fallen under our own ob- 
servation, the veins of the lower extremities, one or both, have been 
affected. Owing to the kindness of Dr. Cursham, we had lately an 
opportunity of examining a very marked case of this kind. It occurred 
in a youth who died in the Brompton Hospital with empyema of the 
left side, and tubercular disease of both lungs. The body was emaciated, 
exceedingly ansemic, both lower limbs highly anasarcous, and traversed 
here and there by superficial veins, distended with dark blood, and feel- 
ing hard and cordy. One limb had first become anasarcous, and after- 
wards the other; no symptoms of phlebitis appeared to have existed. 
The lower part of the vena cava inferior, and all the veins below, as far 
as they were traced (to below the knee), were blocked up by coagula, 
of more or less decolorized fibrin. In many places, the exterior layer 
of the coagulum had almost assumed a membranous appearance, and 
was very closely adherent to the wall of the vessel. It could, however, 
be completely detached by a little care, and then the coats of the vein 
appeared perfectly natural. They had their normal elasticity and 
firmness, and were not even for the most part stained with blood. It 
was evident that their tissue had not been inflamed. The fibrinous 
coagula in several places were somewhat softened, and rendered slightly 
spongy or reticular in their interior. This was due to a spontaneous 
transformation taking place in the mass. Instead of presenting a dense 
network of fibrils, set in an hyaline substance, interspersed with a little 
granular matter, and with a few corpuscles, which was the case with the 
outer layer of a coagulum found in the right ventricle, the softening 
fibrin from the interior of the coagula in the large veins consisted of an 
immense number of various-sized corpuscles, some quite similar to glome- 
ruli, imbedded in a mass of granular and oily matter, with scarce any 
trace of the fibrillar network. This change in the fibrin was evidently 
not such a mere disintegration as a warm temperature might occasion £ 
had it been complete and general it would have led to the breaking up 
of the coagula, and the restoration of the circulation. In other instances 
that we have seen, under the influence of appropriate treatment, this 
actually took place, and all obstruction disappeared. It is very con- 
ceivable how anemic blood, with its vitality generally lowered, and 
especially deficient in the organized living cells, shall tend, particularly 
when it is propelled in a sluggish current by a languid heart, to pass 
into that condition which it spontaneously assumes when withdrawn from 
the influence of the living tissues: and it is very manifest how import- 
ant it is to be aware of the tendency which exists to such an event, and, 
if it occurs, to appreciate its real nature, and not to regard it, as might 
easily be done, as the result of inflammation. The nutrition of some 
parts in the anaemic may be impaired to such an extent that ulcerations 
form spontaneously. The cornea would appear especially likely to 
suffer in this way from not being permeated with vessels. Such in- 
stances of morbid action are very important to notice, as being free 



HYPEREMIA. 87 

from complication, and exhibiting, therefore, more clearly the essential 
nature of a process. Ulceration in this case is clearly not produced by 
inflammation. It is rather interesting to remark, that the most lowly 
organized and the least essential of all the tissues, viz : the adipose, suffers 
less from impaired nutrition in the anaemic state than any other. It is 
by no means uncommon to see persons, especially females, presenting 
a considerable amount of embonpoint, who are manifestly very defi- 
cient in healthy blood. This is the more easily comprehensible, as the 
fat vesicles really seem to be scarce more than so many minute drops 
of exuded oil, included in homogeneous films of protein material. 

The foregoing history of anaemia and spanaemia manifestly relates to 
it as a general condition. It seems very doubtful how far there can 
exist such a condition as partial anaemia, if we recognize a deficiency of 
red corpuscles as an essential feature of this state. Of course, the 
supply of blood to a part may be defective in consequence of various 
causes, but this does not involve any alteration in the quality of the 
fluid transmitted to the part. However, using the term in the sense of 
merely deficient supply of blood, the consequences of such a state will 
be generally those of diminished nutrition, or, more properly, atrophy 
of the part, with more or less considerable impairment of its function. 
If the deprivation of blood be very great, mortification may be the result; 
this has occurred in some cases in which the main artery of a limb had 
been tied on account of aneurism, and the collateral circulation did not 
establish itself soon enough. Even in cases which have a more favora- 
ble issue, the immediate effect of cutting off the supply of blood is to 
occasion weakness, numbness, and reduction of the temperature ; the 
muscles and nerves are, in a great measure, paralyzed, and the heat- 
producing process fails with that of nutrition. When the aorta of an 
animal is tied, its lower extremities, after a time, become as paralyzed 
as if its spinal cord had been divided. The causes of local or partial 
anaemia may be, (1) tumors of various kinds situated so as to press upon 
and obstruct the main artery supplying the part; (2) disease, often 
atheromatous, of the coats of the vessel itself, leading to deposition of 
fibrinous coagula, and consequent obstruction of the channel ; (3) spon- 
taneous coagulation of the blood in an artery ; (4) blocking up of a 
vessel by fibrinous flakes transported from a distance, perhaps from the 
valves of the heart; (5) withdrawal of the nervous influence from a part, 
in consequence of which its nutrition fails. 

It may be observed, that it is difficult in many cases to say positively 
whether anaemia of an internal organ exists ; we cannot observe during 
healthy life what amount of blood as indicated by its color it contains, 
and the changes in the distribution of blood which may ensue during 
the last hours of life, and after, death, will greatly alter the natural 
appearance. 

HYPEREMIA. 

Hyperemia, the opposite condition to anaemia, implies, of course, an 
excessive quantity of blood. The term is commonly applied to accumu- 



88 HYPEREMIA. 

lation of blood in a part, t. e. to local or partial excess, while plethora 
{n-krfio^ a multitude) is that which is used to signify increase of the 
general mass. We will first consider plethora, or general hyperemia,, 
and afterwards partial. 

The characters of marked plethora are strongly expressed, and easily 
discernible. The face is rather full and turgid, and presents a diffused 
redness, often of a slightly purplish tint ; this is especially observable 
in the lips. The conjunctivse are redder than natural, the expression 
of the eye sharp and ferrety. The pulse is full, and more or less strong. 
The temperature of the skin is inclined to be hot, and even in the most 
remote parts it is fully maintained. There is a tendency to headache, 
and not unfrequently there is some degree of drowsiness and disinclina- 
tion to exertion. Persons in this state have good appetites, and digest 
their food well, the secretions all seem to go on naturally, and organic 
or vegetative life is in full vigor. They often lead sedentary lives, in 
consequence of which the waste of the tissues is diminished, and the 
plethoric state augmented, but this is not constant. In many, a con- 
siderable amount of adipose tissue is formed, which, as Dr. Watson 
remarks, may serve as a kind of safety-valve for the diversion of the 
superfluous blood; no doubt this is true; and we are inclined to think 
that the peculiar symptoms of plethora are most marked when there is 
no remarkable accumulation of fat. On account of the increase in the 
quantity of blood it is manifest that complete oxygenation of it must be 
more difficult ; hence, on any exertion the breath is apt to be short, and 
the action of the heart laboring ; hence, also, as Rokitansky observes, 
the blood always presents a certain degree of venosity, as if never 
thoroughly arterialized. A very just distinction is made between two 
principal varieties of plethora, the sthenic and the asthenic. Dr. Wil- 
liams (whose description of them is most excellent) considers that the 
difference between them depends chiefly on different proportions of con- 
tractility and tonicity; that is, on the different degrees of the vital endow- 
ments of the heart and vessels. Doubtless these are increased in sthenic, 
and diminished in asthenic plethora, but we cannot but believe that there 
are other differences also. The quality of the blood in all probability is 
different, and the vital properties of the other organs are also different. 
Generally, it may be said, that in the one the organic life and tone of 
all parts is exalted, in the other proportionately depressed, while in both 
the mass of blood is in excess. Heat of skin, frequency (not, however, 
great) of pulse, with fulness and hardness, keen sensibility, mental and 
bodily activity and energy, a tendency to gout, bilious attacks, and dis- 
ease of sthenic type, characterize the first form of plethora. It is 
observed in the "young, the active, and those of sanguine temperament." 
"Its tendency," according to Dr. Williams, "is to cause general febrile 
excitement, active hemorrhages, fluxes, and inflammations." Dr. Wat- 
son, on the other hand, remarks that the subjects of plethora are not, 
as they might naturally be supposed to be, and as many writers state 
them to be, peculiarly prone to suffer inflammatory complaint. "There 
is general fulness of the vascular system, but no irregularity, nor any 
necessary tendency to irregularity, in the distribution of the blood." 
We are inclined to think Dr. Watson's opinion the more correct of the 



HYPEREMIA. 89 

two. In asthenic plethora the skin is cool, the extremities apt to become 
cold; the pulse is large, but without resistance; it is often slow, some- 
times irregular. The venosity of the blood is marked, the lips are often 
of a livid tint. The contractility and tone of the muscles is deficient, 
the spirits depressed, the mental and bodily activity diminished. It is 
most often seen in the aged, in those who are exhausted by excesses or 
previous disease, "or in whom the excreting organs act imperfectly." 
This latter condition, involving the imperfect depuration of the blood, 
is not a cause of the plethora, at least not to any great degree, but 
rather of the asthenia modifying the plethora. The tendency of asthenic 
plethora, Dr. Williams says, is to produce congestions and passive hemor- 
rhages, fluxes and dropsies, and if continued, structural changes in some 
organs, as dilatation of the heart, enlarged liver, varicose veins, &c. 
Most of these effects, in our opinion, imply a further alteration of the 
crasis of the blood than belongs to uncomplicated plethora. What has 
been termed " excrementitious plethora," seems to be nearly the same 
as asthenic plethora, with impaired action of the excreting glands; this, 
Dr. Williams thinks, may arise from mere stagnation, or imperfect 
motion of the blood, in consequence of which " it becomes loaded with 
urea, lithic and lactic acid, and other effete materials, which unfit it for 
its proper uses, and irritate and disorder the organ through which it 
passes." A more likely cause of such a state of blood we believe to be 
the existence of unobserved organic disease of the kidneys or other 
glands. The characters of the blood in sthenic plethora are : (1.) The 
increase and amplification of the entire mass. Of this we have no direct 
measure, but we may form a tolerable idea of the extent to which it takes 
place, by observing the effect of bloodletting. As much as forty or fifty 
ounces may be drawn at once in some cases without fainting being pro- 
duced, and even this quantity has sometimes been exceeded. Dr. Watson 
mentions a case in which seventy-two ounces were withdrawn before the 
patient became faint. Not only does the system tolerate these large 
losses of blood, but judiciously employed they are highly beneficial; the 
patients are relieved and refreshed by taking off a part of the mass 
which loaded the vascular system. So conscious are they of this, that 
those who "make blood fast," as the popular phrase is, will come and 
request to be bled, often at the spring of the year, when the blood- 
making process seems to go on more actively. (2.) The red globules in 
plethoric blood are remarkably increased, while the fibrin rather inclines 
to be somewhat diminished, and the albumen of the serum undergoes 
little variation. The quantity of water being diminished in proportion 
to the increase of the red corpuscles, it follows that the coagulum formed 
after bleeding will be large, and will be surrounded by but little serum. 
The mass of corpuscles in proportion to the fibrin is so great, that the 
latter cannot contract to the degree it ordinarily does, and hence a larger 
amount of serum is retained within the clot. In sthenic plethora, the 
coagulum is firm as well as large, in asthenic, its cohesion is diminished. 
(3.) A tendency to deficient arterialization may also be mentioned as a 
character of plethoric blood ; perhaps we may connect this with a defi- 
cient production of fibrin, which, as we before stated, may with much 
probability be regarded as an oxidation product. Should this be the 



90 HYPEREMIA. 

case, there would appear some ground for accepting the following view, 
which is only offered as a suggestion. 

The perfectly homogeneous aspect of some of the casts of the renal 
tubules which are found in the urine when fibrinous fluid has been 
draining off from the congested bloodvessels, suggest the possibility that 
fibrin may be particularly applied to the formation and renewal of the 
various homogeneous membranes, such as the limitary membrane of 
gland tubes, the sarcolemma of muscular fibres, the wall of capillary 
vessels. If then in some cases of plethora (the extreme ones) the fibrin 
is much diminished, it is very conceivable that the walls of the capil- 
laries are less perfectly formed, and consequently less able to resist the 
interior pressure of the amplified mass of blood. This would, of course, 
favor the occurrence of hemorrhages, especially such as capillary apo- 
plexy in the brain. 

Among the causes of plethora, the first place, perhaps, is to be assigned 
to a special tendency innate in the system to form an undue quantity 
of blood, or, speaking more exactly, to a too rapid growth and multi- 
plication of the red corpuscles. This, as it requires, so it may produce 
an increased quantity of Liquor Sanguinis, according to the principle 
that the demand induces a supply. When the tendency to form blood 
is considerable, it will manifest itself even in spite of circumstances 
that oppose it; but a similar tendency, in much less degree, will produce 
a most highly plethoric state, if favored by an ample supply of rich food 
and a sedentary life. Indeed, these may have the same effects, even 
supposing no predisposition to plethora at all to exist. It is worth 
remarking, however, that they will not produce this result in all cases. 
In many it would be rather dyspepsia, or some cutaneous disorder, or 
a bilious attack. Most of the circumstances that promote a robust state 
of health, with the exception of exercise, are favorable to plethora, and 
on the other hand, such as depress the general vigor, or induce diseases 
of debility, prevent its development. 1 Asthenic plethora is probably in 
most cases dependent upon an unhealthy state of the Liquor Sanguinis, 
occasioned by impaired action of some of the excretory glands, which 
itself may depend on some latent organic diseases of the same. 

The consequences of plethora have already been in part alluded to. 
They are generally such as result from over-distension of the vascular 
system. On account of its proximity to the heart, its delicate structure, 
and the large supply of blood it receives, it is not surprising that the 
brain should suffer from this cause more than most other organs. Rup- 
ture of some of its thin-walled vessels may take place, or the blood be 
poured out from numerous capillaries; and this, of course, will be still 
more likely to occur, if another consequence of plethora be present, 
viz : cardiac hypertrophy. It is easily conceivable how the increase of 

1 There is no doubt that the cessation of habitual discharges, or their arrest by art, 
especially when suddenly effected, and without any corresponding modification of the 
system, induce a dangerous plethora. This should never be forgotten, not only in treat- 
ing persons who are manifestly of plethoric habit, but even those who seem and are really 
in a different state. It seems that the vascular system, after having been long insuffi- 
ciently filled with blood, cannot bear the amount of distension immediately which in the 
state of health would only be natural to it. 



HYPEE^MIA. 91 

the mass of blood shall require and gradually induce an augmentation 
in the power and capacity of the organ that keeps it in movement. In 
sthenic plethora the hypertrophy will be more pure and simple, in asthenic 
it will be associated, in a greater or less degree, with dilatation. The great 
capacity of the vascular system of the liver will cause it to be enlarged 
by the increased distending force of the blood mass, more, in proportion, 
than many other organs. This will be especially the case if dilated 
hypertrophy of the right chambers exist, and the blood is thrown back 
on the venous side of the circulation. Again, in consequence of hepatic 
congestion, the tributaries of the portal vein will also be congested; and 
this seems more especially to affect the hemorrhoidal plexus of veins, 
which become distended into the little tumors, well known as u piles," 
and often give rise to a salutary hemorrhage. Another hemorrhage, 
not unfrequent in plethoric persons, especially the young, is from the 
veins of the nose. This seems especially to give relief to cerebral con- 
gestion. Menorrhagia may also be dependent on, or at least greatly 
increased, by a plethoric state. The natural determination of blood at 
the catamenial periods will of course be often attended with a greater 
discharge, on account of the increased tension of the vascular system. 
Though we consider it at least doubtful whether the plethoric are more 
prone to inflammation than others, there is no doubt that when inflam- 
mation is set up in them it is more violent, and requires more active 
treatment. Dr. Copland states also that the severer forms of inflamma- 
tory fever in the West Indies affect young and plethoric strangers rather 
than older residents, the aged, and the weakly. Bilious, gouty, and 
renal disorders, especially such as belong to the lithic-acid diathesis, are 
often considered as proceeding from plethora; but it may, perhaps, be 
questioned whether they do not rather take their origin in the causes 
of the plethora itself, the high feeding, insufficient exercise, &c. It is 
not improbable that plethora may play some part in producing a vari- 
cose state of the veins, but it is very doubtful whether aneurismal disease 
is ever occasioned by it. 

We must remark with regard to Local Hyperemia, as we did with 
respect to local anaemia, that it differs from general hyperemia, or ple- 
thora, not only in the less extent to which it exists, but in not involving 
any qualitative alteration of the blood. Local hyperemia, in fact, is 
not exactly local plethora; it simply implies that too much blood is 
accumulated in the vessels of a part, without taking any count of the 
nature of this blood. Hyperemia of a part is a phenomenon which 
naturally attracts attention, and has been considered and commented 
on from the earliest times. It exists in the most various conditions, 
from that of increased vital power and functional activity of an organ, 
to that of cessation of all action in it, its death and decomposition. One 
of the best examples of a physiological and natural hyperemia is afforded 
by the female breast during the period of lactation; the vessels proceed- 
ing to it enlarge considerably, and it manifestly receives much more 
blood than at other times. So great is the flow of blood to the part, 
that it not unfrequently happens, owing to a deficiency of secretory 
power, that the healthy hyperemia becomes excessive, and a cause of 



92 HYPEREMIA. 

inflammatory disease. The limits of physiological hyperemia are pretty 
wide. It is often striking to observe how much more blood is contained 
in the vessels of a part that is actively employed, than would be present 
there under ordinary circumstances. Indeed, there is much to lead one 
to the belief that it is not so much the amount of hypersemia that de- 
termines the transition from the healthy to the morbid state, as the 
alteration of the vital condition of the tissues of the part. In endeavoring 
to study the various conditions under which hypersemia occurs, we cannot 
do better than adopt the arrangement proposed by Dr. Williams, and 
consider, first, hyperemia with diminished motion of the blood in the 
part ; second, hyperemia with increased motion ; thirdly, hypersemia 
with motion partly increased, partly diminished. The first of these 
states may be designated congestion; the second, determination of blood; 
the third, is inflammation. This arrangement has the advantage of 
classing together several conditions, in which hypersemia is a prominent 
phenomenon ; but it is not certain, especially as respects determination 
of blood and inflammation, that it is correct ; or rather, that it may not 
prove a source of error by not being founded on that which is the 
essential circumstance in these two conditions. This, at present, is not 
possible, from the imperfection of our knowledge ; but it may be well to 
bear in mind the above caution. 

Congestion — employing the term to signify excess of blood in a part 
with diminished motion — affects chiefly the small veins of the part, and 
the capillaries that communicate with them. Hence, its color is inclined 
to be of a dark venous tint, unlike the more vivid blush of inflammatory 
redness. The part often exhibits patchy, irregularly-distended vessels, 
which can be emptied by pressure, but gradually fill again. Its tempe- 
rature is not much, if at all, increased ; and the pain felt in it is rather 
aching or dull than acute. The degree of swelling varies according to 
the cause producing the congestion, and other circumstances ; generally 
it is not very great. Congestion may exist alone, but often there are 
present also some exudations, the results either of it, or of the condition 
which gave rise to it. 

The two principal causes which produce congestion are : (1.) Obstruc- 
tions of various kinds to the return of blood through the veins. (2.) A 
relaxed and toneless state of the capillaries and small veins. Of the 
first cause we have a good example in tying up the arm for venesection; 
the current of blood setting towards the heart being obstructed, and the 
artery continuing still to pour in fresh quantities, the capillaries and all 
the veins up to the obstructed part become distended with blood. This 
is marked by the red or purple color of the part, and its swollen condi- 
tion. The same effects will of course be produced in all instances where 
the veins of any organ are obstructed ; obstruction of the jugular veins 
produces congestion of the brain, of the renal veins, congestion of the 
kidney, and so on. The modes in which the obstruction may be pro- 
duced are very various ; to take the brain as an instance, the veins re- 
turning the blood from it may be pressed on by an enlarged thyroid, or 
by a mass of indurated glands, or by an aneurismal tumor. Temporary 
cerebral congestion may also be caused by a prolonged expiration, or by 
holding the breath, especially when muscular exertion is made at the 



HYPEKiEMIA. 93 

same time. The arrest of the blood in the veins in these cases depends 
partly on the diminution of the capacity of the chest which takes place 
during expiration, partly on the suspension of the respiratory movements, 
which cause the blood as well as the air to rush into their respective 
cavities within the thorax during inspiration. Perhaps the very most 
marked instance of the effects of this arrest is manifested by severe 
cases of hooping-cough. The capacity of the chest is narrowed more 
and more by the repeated expirations, and the blood not being drawn 
onwards, but thrown back, accumulates visibly in the face, which becomes 
turgid; in the eyes, where ecchymosis sometimes takes place; and simi- 
larly, 1 though we cannot see it, in the brain, where extravasation may 
also occur, or such congestion as produces an attack of convulsions. 
Obstructive valvular disease of the heart, throwing the blood back on 
the lungs, is the cause of the abiding dyspnoea which characterizes such 
complaints. The condition of the large hepatic veins, and of the inferior 
cava where it receives them, shows that the influence of inspiration must 
be felt as a powerful cause in promoting the circulation through the 
liver ; when this, therefore, is impaired, as is the case in vesicular em- 
physema, or other diseases interfering with the respiratory movements, 
the liver will be congested, and the same will of course occur when in 
consequence of asphyxiating causes the blood does not pass freely through 
the lungs, but accumulates in the right side of the heart, and in the 
large veins. Now, in all such instances of congestion it may be remarked 
that there is no evidence of excitement of the part, if we except, at least, 
the occurrence of convulsions in attacks of paroxysmal cough ; the tem- 
perature of the part is not raised, the functional activity is rather dimi- 
nished than increased, and exudations from the bloodvessels, if they 
occur, show no tendency to organization. Everything indicates that the 
hypersemia is merely the result of a mechanical cause, and that there 
is no primary and special alteration of the vital endowments of the part. 
The second cause of congestion, viz : atony of the vessels, may occur 
either primarily or secondarily. In adynamic fevers, in states of ex- 
treme debility, and perhaps in some persons whose tonicity is naturally 
defective, the vessels of a part become distended with blood, without any 
obstruction existing in the veins which convey their blood away, or with- 
out any previous inflammation or undue excitement having exhausted 
their natural contractility. The whole surface of the body, in some 
fevers of very low type, is covered with patches of congested vessels, and 
it is to be noticed that these are chiefly seated in the under parts, the 
blood gravitating downwards, and accumulating in this situation. Hence 
we derive a hint for a precaution well worth observing in continued fever, 
viz : to alter the position of the patient occasionally, and not to allow 
the blood to gravitate day after day to the posterior parts of the lungs, 
which in consequence are especially prone to engorgement and hepatiza- 
tion. Primary atony of the vessels of the choroid coat of the eye seems 
not unfrequently to occur, and to be the cause of the muscse volitantes 
to which the dyspeptic and others are subject. The vessels of the uterus 
in passive menorrhagia, and those of the vagina in non-inflammatory 
leucorrhoea, are not unfrequently affected by primary atonic congestion. 
It is, however, much more common that atony of the vessels occurs 



94 HYPEK^MIA. 

secondarily in consequence of some previous excitement or inflammation. 
This, in fact, is almost always the case in persons of feeble power when 
they are attacked by inflammation ; when the disease is subdued there 
still remains behind this congested state of the overstrained vessels, 
which being naturally of weak tonicity, are unable to resume readily 
their proper caliber. In persons of more vigorous constitution, the 
original tonicity being greater, the vessels quickly recover their normal 
dimensions as soon as the strain arising from determination of blood is 
diminished; hence convalescence is speedy, and the restoration of the 
part complete. But when the system is naturally feeble, or when inju- 
dicious treatment has rendered a strong system so, then it may be a 
most difficult task to revive the contractility of the languid vascular 
coats, and remove the congestion which necessarily ensues. A healthy 
person may have an attack of acute bronchitis, or pneumonia, and if he 
is properly treated he will recover completely, and be scarce any more 
liable to the disease than if he had never suffered at all. But how dif- 
ferent is it when chronic bronchitis is set up in the aged or debilitated; 
the disease commences generally without very severe symptoms, the 
inflammation does not run high, it may be soon in great measure sub- 
dued ; but after that is accomplished, the capillaries of the bronchial 
mucous lining are unable to resume their tone, or they resume it par- 
tially, and easily lose it again when they are exposed to the slightest 
strain, and so the congestion occurs over and over again, until the vessels 
become mere flaccid channels gorged with slowly-moving blood, and pour- 
ing out exhausting exudations of muco-purulent fluid. It is very appa- 
rent that the longer the vessels remain congested, the more difficult it 
must be for them to recover their normal dimensions, and hence we 
derive the valuable hint to subdue active inflammation in every instance 
as quickly as possible, that the strain upon their walls may be lessened, 
and when this is accomplished, to turn as soon as is prudent to remedies 
of astringent and tonic character. This condition of atonic congestion 
is often seen in the conjunctiva after it has suffered an attack of acute 
inflammation, and we can scarce have a more valuable lesson than the 
observation of such cases, and of the Isedentia and juvantia offered us. 
A case of this kind is related in Mr. Tyrrell's work, vol. i. p. 24, which 
from the first time we read it has never passed from our mind; and 
often has the valuable instruction it conveyed been the means of direct- 
ing us to successful treatment. It shows how, besides the local signs of 
atonic congestion, the general condition of the system is also to be con- 
sidered, and that, if this be found in an enfeebled state, no means will 
be nearly so efficacious in removing the congestion as those which 
impart tone and vigor to the tissues generally, and to the vessels in 
particular. 

Besides actual inflammation, over-use of a part may occasion conges- 
tion of its vessels. Of this we have an instance in the congestion of the 
choroid, which is so common in those who exert their eyes very much 
upon minute objects. An organ which has been secreting with unusual 
activity is sometimes found congested with blood. This we have 
observed in the kidneys of diabetic persons ; however, it is not con- 
stantly the case by any means. When it occurs, it is presumable that 



HYPEK^MIA. 95 

the continued flux to the part had weakened, by the strain it caused, 
the contractility of the vessels. The influence of cold in producing con- 
gestions of internal organs cannot be doubted. To this we must ascribe, 
in part, the prevalence of chest affections during the colder part of the 
year, the blood being repelled inward from the surface by the constring- 
ing effect of the cold upon the vessels. The same cause also must be 
the chief agent in occasioning attacks of apoplexy, which have been ob- 
served to be greatly more frequent during a very cold season than during 
a mild one. The effect of the malarious poison in producing conges- 
tions of the internal organs is still more potent than that of cold. With 
every paroxysm the liver and spleen become greatly distended during 
the cold stage ; and to such an extent may this take place, that the lat- 
ter organ, extensible as it is, has been ruptured, and fatal hemorrhage 
ensued. Posture is a very efficient cause in producing congestion. It 
has already been alluded to, when instancing the pulmonary congestions 
that occur in fever ; but the most marked examples of its effects are 
seen in the lower limbs. Here the returning venous current has to 
overcome the force of gravity, and though while the vessels maintain 
their tonicity, and the valves of the veins are efficient, this retarding 
force does not produce any effect, yet when the conditions are altered it 
becomes speedily manifest. Persons of feeble constitution, who are 
obliged to remain for the greater part of their time in an upright posi- 
tion, laboring hard and living poorly, are exceedingly liable to a con- 
gested, thickened, and indurated state of the integuments of the lower 
part of the legs and feet. The veins proceeding from these parts — and 
especially the large superficial veins of the limb — are seen tortuous, 
enlarged, distended, and varicose. They are evidently gorged with 
slowly-moving blood, the column of which, greatly enlarged in bulk, has 
much more difficulty in resisting the force of gravity than in the natural 
state. Such congestions proceed very soon to ulceration, which is apt 
to assume a sloughing form, and which can only be healed by means 
which bring about a more healthy circulation. These are, of course, 
directed to take off the force of gravity by the recumbent posture, to 
empty the distended vessels, and to supply, by external equable pres- 
sure, the defective tonicity of their walls. It may, perhaps, be ques- 
tioned, whether the class of congestions from this cause should not have 
been included under those arising from venous obstruction, as the con- 
dition of the vein itself is such as to create an obstruction to its own 
current. Withdrawal of nervous influence from a part is sometimes the 
cause of congestion taking place in it. Mr. Simon records a case in 
which, after the ulnar nerve had been torn across at the inner condyle, 
the two inner fingers of the hand of the same side " had become swollen 
and livid with vascular injection." Disease of the trigeminal nerve, de- 
stroying its functional capacity, has often been observed to occasion 
inflammation and ulceration of the eye, and in some cases of the parts 
adjacent. This inflammation, it is most probable, was rather of the 
nature of atonic congestion, at least at its outset. It is not, however, 
to be concluded that the walls of the vessels lose their tonicity whenever 
the nerves of a part are unable to discharge their functions, or that this 
is actually dependent on nervous influence. No doubt it is the special 



96 HYPEK^MIA. 

endowment of the vascular membranes, and only capable of being 
affected by the action of the nerves, as well as by direct stimulus. The 
effect of an atonic state of the walls of the vessels is well illustrated by 
an experiment performed by Dr. Williams : he adapted to a syringe a 
tube with two arms, one of which was connected with a metal tube, and 
the other with a portion of dog's intestine, of the same length as the 
metal tube, but, when distended, double its diameter. Water was now 
thrown in by the syringe, and the quantity discharged from the open 
ends of each of the two tubes estimated. The metal tube in the same 
time yielded three times more liquid than the intestine. Now a vessel, 
whose wall is possessed of a proper degree of contractility, may be com- 
pared to the metal tube. The force of the heart communicated by the 
fluid to its walls is not lost, but reacts again immediately upon the fluid 
and drives it onward. The vessel, with atonic flaccid walls, resembles 
the intestine, which yielded to the distending force of the column of 
fluid, and, from not reacting upon it, allowed a great part of the force 
to be lost as an impelling influence. 

The effects of congestion have already been partially noticed. They 
have reference mainly to two circumstances : one, the impairment of the 
vital actions of the part, the other, the effusion from the overloaded ves- 
sels of watery, albuminous, or mucous fluids. When the arm is tied up 
for venesection, a sensation of numbness, weakness, and chilliness, is 
felt after a time, showing that the sensibility and contractility of the 
limb are impaired by the congestion which has taken place. In the 
hepatic and renal congestions, which often are produced by obstruc- 
tive disease of the heart, the secretion of bile and of urine is commonly 
diminished, or morbidly affected. Cerebral congestion interferes mate- 
rially with the free exercise of the functions of which the brain is the 
instrument. This impairment of vital (i. e. special) power depends 
partly on the more increased quantity of blood in the part, which, being 
greater than is proportionate to its functional activity, overloads and 
oppresses it. If it be true — as we shall see reason to think that it is — 
that the supply of blood to a part is, in a measure, dependent on the 
vigor and energy of life which that part possesses, it will not be difficult 
to conceive that an over-supply of blood will have an injurious and de- 
pressing effect on the same vital powers. But a still more powerful, 
and quite unquestionable, cause of vital depression in a congested part, 
is afforded by the altered condition of the blood itself, which, semi-stag- 
nating in the capillaries and veins, becomes more venous than it should, 
and otherwise unfit for the healthy nutrition of the tissues. The slough- 
ing ulcers which form in the congested and thickened integuments of 
the lower limbs, when the veins are enlarged and varicose, are a striking 
instance of the lowered condition of the vitality of those textures. Long- 
continued congestion of the liver, from disease of the heart, produces a 
very remarkable effect on the parenchymal cells. They become very 
greatly loaded with yellow matter (which does not appear to be true 
biliary, but rather bile pigment); in extreme cases, the majority atrophy, 
and are reduced to a mere granular detritus, while the capillary inter- 
cell-spaces become enlarged. These changes afford some explanation 
why the secretion of bile is interfered with, and also why jaundice 



HYPEREMIA. 97 

occurs. The effusions that take place from congested parts are cer- 
tainly the most prominent phenomena of the condition. They will be 
most abundant, as a general rule, when the congestion depends on 
venous obstruction ; so that, while fresh blood is being poured into the 
part, no exit can be found for it, except that which the exudation affords. 
They may also be extremely abundant in some cases, in which not only 
the tonicity of the vessels is entirely lost, but the texture of their walls 
is altered, so that they no longer oppose any obstacle to the escape of 
their contents, but allow them (the fluid part) to transude with great 
facility. Such is, no doubt, the case in instances of bronchorrhoea, 
chronic diarrhoea, and leucorrhoea, where large quantities of fluid are 
continually passing off from the toneless vessels, but where no venous 
obstruction exists, or none that is commensurate to account for the dis- 
charge. The effect of remedies in these cases shows that the discharge 
is dependent on the cause we have mentioned. Under the administra- 
tion of turpentine or astringents the vessels regain their tone, and no 
longer pour out their contents. Though the vascular atony may in 
such states have originated in congestion, yet as this is removed by the 
effusion while the atony remains, they come at last to be rather instances 
of passive flux, or dropsy. Chronic ascites, in which the smaller 
branches of the portal vein may be so obstructed that no fluid can pass 
through them, presents an exquisite instance of effusion depending upon 
venous obstruction. The fluid effused in the peritoneal sac varies a good 
deal, chiefly as to the relative proportions of water and albumen which 
it contains. In the table subjoined at page 116, one instance is seen in 
which the water amounts to 988 per 1000, and the albumen to only 0.9, 
while in another the water does not exceed 704, and the albumen is in 
the prodigious quantity of 290. Not only does a more or less watery 
serum exude, but fibrin not unfrequently accompanies it. Large flaky 
masses of fibrinous coagula are not uncommonly found in the peritoneal 
cavity after death in cases of ascites, and the same are also seen occa- 
sionally in the fluid evacuated by paracentesis. We have also seen 
blood-globules so uniformly dispersed through the fluid, that there could 
be no doubt that they had escaped from the congested sub-serous capil- 
laries, and were not accidentally mingled with the effusion. The same 
products of congestion also occur in the urine when obstructive disease 
of the heart throws back the blood on the veins. The secretion is albu- 
minous, contains fibrinous casts of the tubes and blood-globules. De- 
cided hemorrhage may also occur, as the result of extreme congestion, 
which may be dependent either upon venous obstruction or upon an 
atonic state of the vessels. Melsena, or hemorrhage from the bowels, 
is an instance of the first, passive menorrhagia and epistaxis, of the 
latter. 

We shall return to the consideration of effusions proceeding from 
congestion, when we speak of the results of hyperaemia generally. It 
is a remarkable and instructive fact, that congestion of parts never 
seems to occasion hypertrophy ; or, if this should appear to have taken 
place, closer examination proves that rather the reverse is the case ; 
that the hypertrophy is what Rokitansky calls unreal. Thus, a large 
baconv spleen or liver may appear to be hypertrophied; but the in- 
v 7 



98 HYPEREMIA. 

crease in size is not due to the formation of fresh natural tissue, but to 
the infiltration and addition of an unnatural product, among which the 
real structure is found atrophied. In these particular instances the 
deposits may not have proceeded from congestion ; but they afford an 
exact illustration of what often takes place in congestion in a less de- 
gree. It seems also very doubtful whether simple passive hyperemia, 
as such, does produce even these unreal hypertrophies, or whether in 
all such instances the crasis of the blood is not also altered in some 
special manner. After very numerous examinations of congested livers 
from persons dying with heart disease, we have not been able to con- 
vince ourselves that the hyperaernia gives rise to any new product, or 
that it is an exciting cause of the cirrhotic alteration which may also 
exist. We have already pointed out the impairment of vital power 
which congestion occasions, and the causes inducing it, which seem to 
afford an adequate explanation of the non-tendency to growth and de- 
velopment which is observed both in the affected part itself and in its 
interstitial effusions. The following sentence from Mr. Simon's lecture 
recognizes and similarly explains the same fact: "It is true, that 
much blood is contained in the affected tissue ; but it is blood that has 
insufficient means of renewing itself; and from its long detention in the 
part it acquires, in an extreme degree, the character of venous blood. 
Thus, as regards mere bulk of blood, the part is over-supplied, but, in 
respect of the quality of blood, it may be said to suffer what is equiva- 
lent to anaemia : accordingly, the elements of its texture fall into a state 
of atrophic softening, which terminates in the formation of an ulcer. I 
think it not improbable that the same fact may contribute to explain 
the continued non-development of those effusions which arise from pas- 
sive hyperaernia." It thus appears that atrophy, rather than hyper- 
trophy, is likely to be the result of abiding congestion of any part. 

The effects of congestion of a part, especially if it be one of some 
magnitude, may not be confined to the part itself, but may affect the 
system generally. This appears in two respects, one being a degree of 
faintness and depression, occasioned by the withdrawal of a consider- 
able quantity of blood, from active circulation ; the other, an injurious 
influence exercised on the whole blood mass by the deteriorated por- 
tion, which slowly and partially returns into it again from the seat of 
congestion. It is clear that an excess of blood poured into one part, and 
detained there, must leave others imperfectly supplied; the local hyper- 
aernia, according to its extent, produces a degree of general anaemia. 
That blood which has long been stagnant in a part must be in an un- 
healthy state is very comprehensible, and that, by its mingling with the 
general mass of blood, deterioration of the same will be induced, and 
therewith a cachectic state. Thus, when a congested state of liver exists,. 
there are, frequently, abundant lithates present in the urine; the blood, 
returning from the liver, conveys into the circulation matters which 
induce an unnatural state of the renal secretion and more or less of 
general disorder. 



HYPEREMIA. 99 



ACTIVE HYPEREMIA.— DETERMINATION OF BLOOD. 

This is the second variety of local hyperemia that we have to con- 
sider. The general phenomena of this condition are manifestly different 
from those of passive hyperemia, and convey the idea of increased 
activity and vigor in the vital process. The flow of blood to the part 
is increased ; the capillaries, without being greatly distended, are well 
filled, and give a more or less suffused red blush to the face, very differ- 
ent from the duller tint of congestion. In consequence of this filling of 
the capillary plexus, and, perhaps, also of some slightly increased blas- 
temal exudation, the turgescence of the part is increased, and its tem- 
perature elevated. The arteries leading to the seat of active hyperemia 
often pulsate with more than ordinary force, so as to have given rise to 
the idea and term of "increased vascular action." They must also be 
enlarged to admit the greater quantity of blood that the part receives, 
and this enlargement becomes permanent ; that is to say, the whole 
vessel assumes larger dimensions, when the hypersemia is a healthy and 
natural state. The veins also enlarge, but are not distended as they 
are in congestion. The sensibility of the part is commonly increased ; 
its function may be, or may not, and the same is true of its growth. 

This brings us to the inquiry, whether active hypersemia may not be 
distinguished into two forms, one to be regarded as healthy, associated 
with increased vital power and capacity for action ; the other morbid, 
attending upon and promoting unnatural action, resulting in disease 
and decay. There are many well-known and oft-quoted examples of 
healthy hypersemia, such as the female breasts during gestation and 
lactation, the uterus during the period of pregnancy, the gums during 
dentition, the mucous membrane of tlie stomach while the secretion of 
gastric juice is going on, and, generally, it may be said, every organ 
during the time of increased activity and employment. Now, we think 
it may be affirmed, that, in the above instances, the most important and 
characteristic phenomenon is the increased functional energy and vigor 
of the hyperaemic part ; this we believe to be the main and essential 
circumstance of which the increased blood-flow is a sequel. Nay, there 
are many instances, especially among secretory organs, in which the 
great increase of the product proves that a corresponding increase of 
the supply of blood must have taken place ; a true hypersemia, in one 
sense, exists, but it is not apparent, because of the active transforma- 
tion which is going on. How marked is the difference between this 
condition and congestion ! In the one, functional activity and mole- 
cular change at its height, with vascular injection more or less consi- 
derable, but not varying in direct, rather in inverse, ratio to it; in the 
other, vascular injection extreme, while the functional activity is ex- 
tremely depressed. Now, in proportion as active hypersemia departs 
from the physiological condition and becomes morbid — that is to say, 
approaches towards inflammation — in the same degree does the vital 
energy and activity of the part appear to be lowered, and the hyper- 
semia becomes the more marked phenomenon. Thus, a diuretic drug 
shall be administered to two individuals: in the one, the flow of urine 



100 HYPEK^IMIA. 

shall be considerably augmented, the vital power of the kidney predo- 
minating over the hyperemia excited ; in the other, the flow of urine 
shall be diminished, and the secretion become bloody and albuminous, 
evidencing the predominance of the hyperemia over the vital power. 
So, too, in fever. The skin, at one time, shall be dry, and burning, 
and red, with vascular injection, but its vital power of secretion and 
exhalation is in abeyance. But a change comes, the tissue regains its 
functions, and pours out a healthy moisture on the surface ; and now 
the hypersemia, though it may continue in some degree, is no longer 
predominant. How different must be the condition of the gastric mu- 
cous membrane in the hyperemia excited by a few grains of ginger, 
and that produced by a few grains of arsenic! No doubt the one form 
of active hyperemia may pass into the other. The quantity of blood 
which a healthy tissue was able to employ, and which was requisite for 
the unusually vigorous discharge of its function, may become too much 
for the same tissue when debilitated by over-use. A brain ministering 
to an active mind, requires and receives a greater supply of blood than 
that of the waterman " who rows along thinking of nothing at all." So 
long as the cerebral energy is not overtasked, the hyperemia will tend 
to no injurious result, but will only supply the necessary pabulum for 
the material changes connected with thought. When, however, the 
time arrives that the delicate organ needs repose, then if the strain be 
continued, and the hyperemia kept up, it is manifest that a morbid 
state will soon supervene, in which the hyperemia may yet further 
increase, and the natural energy be still more diminished, till, together 
with symptoms of disordered and erring action, inflammation, or some 
other result of hyperemia, occurs. The phenomena we have alluded 
to are of every-day occurrence. No doubt can exist about their reality, 
though different opinions may be entertained as to how they should be 
interpreted. We shall immediately proceed to consider more closely 
the different views that have been advanced, but we would ask especial 
attention to this point which we have dwelt on, viz : that in one form 
of active hyperaemia, the vigor of the tissues for vital action is increased, 
while, in the other, it is diminished. In the one the hypersemia sup- 
plies a want, in the other imposes a burden. 

Now, before we enter on the consideration of the mode in which 
active hypersemia is brought about, let us refer shortly to one or two 
physiological points, which must form the very basis of all our attempts 
at explanation of the phenomena. All tissues may be regarded as con- 
sisting of vessels, nerves, and the proper elements of the tissue. The 
vessels, it is true, may be more or less closely woven up with the tissue, 
or even may not actually penetrate it, but still they are essential. The 
nerves convey an influence which may affect the bloodvessels or the 
tissue. The elements of the tissue, be they cells, or originally derived 
from cells, have certain special endowments, which, when called into 
action, increase the flow of blood to the part ; at least, this seems only 
another form of putting the undoubted fact — that exercise of a part 
causes more blood to flow thither. The bloodvessels consist of arteries, 
capillaries, and veins. The arteries have a truly contractile coat, 
which, under some kinds of. stimulation, may even produce obliteration 



HYPEREMIA. 



101 



of the channel. This contractile coat resembles, but is not quite iden- 
tical with, organic muscular fibre. It possesses, so far as we know, no 
other property than that of contracting. There is not the least reason 
to suppose that it has any power of active dilatation. The capillaries 
have a simple, homogeneous, membranous well, in contact with the tis- 
sue proper of the parts. It does not appear that this possesses any con- 
tractility. The contractility of the veins has generally been considered 
much more doubtful than that of the arteries. Weber did not find 
them respond to the stimulus of cold as the arteries did. Mr. Wharton 
Jones, admitting that they do undergo some variation in size, in virtue 
of the contractility of their outer coat, still expresses himself clearly, 
"that constriction or dilatation of veins cannot be observed actually 
taking place, as it may be in the case of the arteries;" and "secondly, 



Fig. 9. 




Contracted artery, from Wharton Jones's Essay. 

that the degree of constriction or dilatation which the veins in any case 
present, is very small in comparison with that which the arteries un- 
dergo." Professor Paget's observation seems conclusive as to the con- 
traction of both veins and arteries under a mechanical stimulus. He 
says, "if, as one is watching the movement of blood in a companion- 
artery and vein, the point of a fine needle be drawn across them three 
or four times, without apparently injuring them, or the membrane over 
them, they will both presently gradually contract and close ; then after 
holding themselves in the contracted state for a few minutes, they will 
begin again to open, and, gradually dilating, will acquire a larger size 
than they had before the stimulus was applied." It must be noticed, 
that Mr. Paget's observation has reference to the wing of the bat, while 
Mr. Wharton Jones's conclusion has been formed from examination of 
the web of the frog. The former, as a warm-blooded mammal, is no 
doubt a better representative of man than the reptile. 

What we can see, by the microscope, in parts that are the seat of 
active hyperemia, in consequence of the application of a stimulus, is 
by the very accordant testimony of the best observers as follows: When 
a moderate irritant, such as tincture of capsicum, or a drop of some 



102 HYPEREMIA. 

essential oil, is applied to a transparent part, the arteries speedily di- 
late, and a rapid flow of blood through them ensues. This seems to 
tell on the capillaries and veins, which become dilated also, so that 
vessels, which before scarcely admitted blood-globules, are now traversed 
by great numbers. Sometimes the dilatation seems to be preceded by 
constriction of the artery ; but this does not constantly occur, and 
when it does, is of brief duration. It has been often said, that the 
flow of blood was accelerated in arteries that were contracted ; but the 
reverse seems rather to be the truth. It is the dilatation of an artery 
that causes the current to become rapid, doubtless in consequence of the 
less resistance opposed to the vis a tergo of the heart. Professor Pa- 
get writes : " As the vessels are contracting, the blood flows in them 
more slowly, or begins to oscillate ; nay, sometimes, even before the 
vessels begin visibly to contract, one may observe that the blood moves 
more slowly in them, as if this were the first effect of the stimulus. 
Nor am I sure that I have ever seen (what is commonly described) the 
acceleration of the flow of blood in the contracting vessels. Such an 
acceleration, however, is manifest, as the vessels reopen ; and as they 
dilate, so, apparently in the same proportion, does the flow of blood 
through them become more free, till at length it is quite manifest that 
they are traversed by both fuller and more rapid streams than passed 
through them before the stimulus was applied." Mr. Wharton Jones's 
observation is to the same effect : " In one case," he says, " the arteries 
of the web were more or less constricted, the circulation sluggish, the 
blood in the capillaries here and there stagnant. A drop of the solu- 
tion of sulphate of copper with vin. opii was applied, whereupon the 
arteries immediately became dilated, and the circulation brisk." Dr. 
Williams, in his work, so often referred to, had previously maintained 
and clearly illustrated the same view. It may therefore be considered 
established, that in active hyperemia one principal feature is dilatation 
of the arteries ; while in passive hyperemia, the veins and the capilla- 
ries opening into them are dilated, and the arteries either are not en- 
larged, or are constricted. Now, it may very naturally be asked, in 
what way does the stimulus applied bring about dilatation of the ar- 
teries ? All that we know of the habits of contractile tissues, leads us 
to believe that they can only respond to a stimulus by exerting their 
contracting power, and there is no known instance of active elongation. 
How is it, then, to be conceived that a stimulant, applied locally, which 
does not affect the action of the heart, can cause dilatation of the blood- 
vessels ? Henle conceives that the stimulus, acting on the sensory 
nerves of the part, excites in them a state, which, being communicated 
to the spinal centre, is reflected on the vascular nerves, occasioning 
them to become paralyzed, and therewith the contractile coat of the 
vessels also. This theory (the neuro-pathological), though it has found 
credit with many, really seems only to shift the difficulty from the 
bloodvessels to the nerves. It is just as contrary to experience that 
excitation of a sensory nerve should paralyze a motor, as that the stim- 
ulation of a contractile tissue should make it elongate. Stilling's modi- 
fication of the Neuro-pathological Theory, rests on the assumption that 
there is a continual reflected influence from the sensory upon the vas- 






HYPEREMIA. 103 

cular nerves, so that when the sensory are paralyzed, the vascular are 
paralyzed too, and when the former are excited, the latter are also ; but 
if, as we know, a paralyzed limb can be the seat of active hyperemia, 
and if, as Mr. Simon has shown, u the absence of a spinal cord, or the 
division of all the roots of the nerves, or the section of the lumbar and 
sciatic plexus, will make little or no difference as to the certainty with, 
which an irritant, applied to the web of a frog's foot, will quicken the 
circulation there, and subsequently lead to its retardation and arrest," 
it is abundantly clear that all such views are quite inadequate to account 
for the phenomenon in question. It is to be remembered, that con- 
traction and dilatation of vessels, and increased and more rapid flow 
of blood through them, are things that, by the aid of the microscope, 
we can see ; but the molecular movements of nutrition and secretion, 
which we believe to influence and modify the circulation through a part, 
we cannot see ; they are as real and as potent, but they are, except in 
their results, invisible. Feeling, however, the importance of ascertain- 
ing every cause that we suppose to be concerned in the production 
of a phenomenon, to be a "causa vera," we briefly put together the 
arguments which appear to us conclusive, that what we have called the 
"nutrition force," and Dr. Carpenter the "capillary," does really exist, 
and is concerned in producing the state of active hyperaemia. (1.) 
When a part is not employed (a limb, for instance) for some time, 
it wastes and atrophies. Its bloodvessels become smaller, and its tem- 
perature falls. Manifestly, the circulation of blood through it is di- 
minished. (2.) When a part (as a limb) is actively employed, it en- 
larges, its temperature is increased, its bloodvessels are more developed, 
and the quantity of blood passing through it is evidently greater. (3.) 
When a gland is excited to increased action, as the mamma of the 
female, the flow of blood to it is increased, and the vessels become en- 
larged. (4.) In plants it has been observed, among other instances 
of the influence of local stimuli, that a branch of a tree, growing in 
the open air, which is brought into the atmosphere of a hothouse, will 
vegetate during the winter, and draw up sap through the stems and 
roots, while the other branches remain in their ordinary state. (5.) 
In many of the lower invertebrata; the movement of the nutrient fluid 
seems to be evidently independent of the action of a heart on the ves- 
sels. (6.) Dr. Houston's case of an acardiac foetus has proved, in the 
judgment of those most competent to decide, 1 "that a foetus may grow 
to a considerable size, and have its various tissues well developed, with- 
out any connection with the twin foetus, by means exclusively of a circula- 
tion of its own, of which a heart forms no portion, or upon which it 
can exercise but a very remote influence." (7.) Though the phenome- 
non of blushing, and some other local determinations of blood, may 
be accounted for by an alteration taking place in the caliber of the blood- 
vessels, their channels being widened, and more blood admitted, yet 
that of hyperaemia, excited by a local stimulus, appears to us quite 
impossible to explain in such a way. We would refer more particularly 
to the interesting experiment, recorded by Mr. Simon (p. 96 of his 

1 Todd and Bowman, Phys. Anat. vol. ii. p. 872. 



104 HYPEREMIA. 

Lectures on Pathology), in which hyperemia was induced by the local 
application of a stimulus to a part, which had lost all trace of sensi- 
bility. This appears to us to atford conclusive proof, that neither the 
action of the heart, nor that of the bloodvessels, but only the nutritive 
force, heightened by the action of the stimulus, could have produced 
the local erythema. This justly eminent authority adds: "Altogether 
we may, I think, take it as an established certainty, that the first 
change which occurs in an inflamed or overgrowing part, and which 
leads to its becoming loaded with blood, is not a reflex change operated 
through the nerves, but is a direct change, operated by the living mole- 
cular structure of the part on the blood which traverses it, or on the 
vessels which convey that blood." He compares it to "a vortex, es- 
tablished in the place of the irritant, causing all the adjoining stream- 
lets of blood to converge in swifter channels towards it." Professor 
Paget says : " I think I can be quite sure that the velocity of the stream, 
in any vessel of an inflamed part, is not determined by the diminution 
or enlargement of the channel. Without change of size, the stream 
may be seen decreasing from extreme velocity to complete stagnation. 
On what the alteration of movement of the blood in such a case depends, 
I cannot tell; but we have facts enough to justify such an hypothesis as 
that there may be some mutual relation between the blood and its ves- 
sels, on the parts around them, which, being natural, permits the most 
easy transit of the blood, but, being disturbed, increases the hinderances 
to its passage." 

The foregoing arguments and authorities must be allowed, though in 
opposition to Dr. Williams and Rokitansky, to carry very considerable 
weight with them; and the remark will appear justified, that it really 
seems far too exclusive and one-sided a view to consider only the blood 
and the vessels as the agents concerned in hyperemia, the common ini- 
tiatory step of inflammation, and to deny to the essential elements of 
the part any share in the production of a state by which they are so 
importantly affected. We therefore recognize an increased attraction 
of the blood towards the part which is stimulated, as one cause of 
active hyperemia, and the principal, and we regard the dilatation of the 
arteries as a secondary, but not unimportant. But the influence which 
the tissues exert on the circulation, in virtue of their " nutritive 
power," we may be sure is not only an attraction which may be in- 
creased or diminished, but also an alteration which the attracted blood 
undergoes, and, having undergone, is either repelled or pushed on by 
the advancing current. We may illustrate this motive influence by the 
example of light bodies, when acted on by electricity. Two pith balls, 
one of which is in a negative, and the other in a positive state, will 
attract each other strongly ; but as soon as they both become negative 
or positive, they forcibly repel each other. Some similar relation must 
subsist between the blood and the tissues. The arterial blood is hete- 
rogeneous to the tissue, and is attracted to it. Having become venous, 
it is no longer so, and it ceases to be attracted, perhaps even is repelled. 
Now, we may conceive the attractive force to persist, or even to be ex- 
alted, while the change impressed in nutrition may be greatly lessened. 
Blood will then accumulate in the part, from not having undergone that 



HYPEK^HIA. 105 

vital change which it should, and the part will be hyperaemic. This 
would be the case in active hyperemia of a morbid kind — in that which 
forms the first stage of common inflammation, in which the vital endow- 
ments of the part are lowered, and its functional activity lessened. In 
healthy hyperemia, on the other hand, the attractive and the changing 
influences are both increased. The blood does not accumulate, but only 
ministers adequately to the increased functional activity of the part. 
We are anxious to avoid, as far as possible, speculating beyond the 
limits of actual observation, but we would ask, whether some such inter- 
pretation as we have offered be not necessary to explain the different 
event in two cases of suckling females, one of whom has the child put to 
the breast early, and by the mental and psychical influence brought to 
bear, has the functional activity of the gland aroused, so that the hy- 
peraemia as it arises is converted into a copious flow of healthy milk; 
while the other, who has the child kept from her for two days, and 
whose mammae are left unaroused and unstimulated, suffers from over- 
whelming hyperaemia, which issues in inflammation and suppuration. 

We now pass from the consideration of the mode in which active hy- 
peraemia is induced, to that of its effects. These, as already intimated, 
are different in the healthy and morbid varieties. In the first, the 
growth of the part, if the hyperaemia continue long enough, is increased; 
it undergoes a true hypertrophy. Of this we have the best examples 
in the muscular tissue. At the same time, the function is more vigor- 
ously exercised; it has more capability for, and it performs more work. 
Of this the brain, under the influence of moderate determination of 
blood — such as some of our great orators used to induce by pretty free 
libations of wine — is a good example. Similar instances among glandu- 
lar organs we have already noticed. That of the ovaries and uterus, at 
the catamenial periods, is very remarkable, and is evidently connected 
with the reproductive nisus, which manifests itself especially at these 
epochs. There seems no ground whatever to regard it as originated by 
nervous influence, but rather as the result of a mode of growth and 
nutrient action peculiar to these organs. The discharges of the ovarian 
ovum, and the catamenial flow, are the results of this hyperaemia, but 
it is itself excited by the spontaneous activity of the structures. Thus 
curiously, as we see also in many other instances, are linked together 
the increased action of an organ, and the increase of its supply of blood; 
in the healthy state, the former usually takes the initiative, and pro- 
duces the latter, but is itself reacted on by it, increased, and carried on. 

But it is rather with morbid hyperaemia that we are concerned as 
pathologists. This is, in a very great number of instances, the com- 
mencement of inflammation ; but we shall not speak of inflammation 
as one of its results, but consider it separately. The effects of morbid 
hyperaemia are generally unnatural excitement, or oppression of an 
organ. The part contains more blood than it is able to manage, its 
healthy play is interfered with, and it is either goaded into a false, 
aimless, and exhausting activity, or it is actually oppressed and enfee- 
bled directly. The chief features of the condition are, probably, in- 
creased attraction of blood to the part, with diminished vital change, 
and undue dilatation of the arteries leading to it. 



106 • HYPEREMIA. 

If the brain be the seat of determination of blood, in a morbid sense, 
there will be throbbing of the carotids and their superficial branches, 
restlessness, more or less intolerance of light and sound, diminution of 
the power of attention and application, dreamy and disturbed sleep, 
irritability of temper, attacks of giddiness, &c. The face and eyes are 
apt to be flushed, and the feet cold. The uneasy sensations about the 
head are increased by stooping, or the recumbent posture. The kidney, 
in cases of acute anasarca, manifests an excellent example of morbid 
hyperemia. It is enlarged and turgid with blood, but its texture is 
not apparently altered. Its secretion is scanty, loaded with albumen, 
and with fibrinous concretions, and epithelium of the tubes. No doubt 
can exist that its functional energy is gravely impaired. In active 
menorrhagia we have a third instance in which, from various causes, a 
morbid hyperemia of a hollow organ lined by a secreting mucous mem- 
brane is induced, the results being pain and uneasiness in the region of 
the affected part, increased sensation of heat, tension and throbbing, 
which are relieved by the discharge of a fluid more completely san- 
guineous than the natural secretion; in fact, by an almost real hemor- 
rhage. In such an instance, it is not only the mucous lining of the 
uterus that becomes hypersemic, but the whole organ, with its thick 
muscular walls. Their tissue is loosened up and swollen by the quan- 
tity of blood admitted, so that the size of the organ is increased; and 
if this hyperemia should not in great degree subside, the result may 
be a permanent enlargement and congested state of the uterus. The 
foregoing examples, taken from different organs, will serve as sufficient 
illustrations of the effects of active hyperemia. It seems, however, 
desirable to allude, somewhat more in detail than has yet been done, to 
hemorrhage, flux, and dropsy, considered as results of hyperemia in 
general. 

These may be regarded as the effusions of hyperemia, as distin- 
guished from inflammation. No doubt they do also occur in cases 
where inflammatory action is proceeding; but still they are not the 
special and characteristic products of this state. 

Hemorrhage implies the effusion of blood in mass, not merely of 
some of its constituents ; exudations, therefore, which are only colored 
by hsematin, do not constitute hemorrhage. The best character of an 
hemorrhagic effusion is the presence of large masses of blood-globules 
imbedded in fibrinous coagula. Such may be found either from an 
opening in a vessel of some magnitude, or from numerous capillaries. 
In every case where blood is effused in any quantity, the walls of the 
vessels must have given way; and perhaps this is the case in every in- 
stance where a blood-globule escapes from its channel, though it is not, 
to our minds, absolutely certain that there is no such thing as the he- 
morrhage by exhalation of the older writers. Hemorrhage may take 
place either in solid parenchymatous organs, or in those that inclose 
cavities and form canals. In the first case, the substance of the organ 
undergoes more injury than in the latter. An effusion of blood into 
the brain is a most serious thing ; on the surface of the Schneiderian 
membrane it is a mere trifle. When a large quantity of blood is sud- 
denly extravasated in a solid organ, it ploughs up and disorganizes the 



HYPEREMIA. 107 

tissue, and forms therein a cavity for itself, where it lies like a mass of 
black currant jelly : the walls of the cavity are usually ragged, and 
soon become stained to some depth by altered coloring matter. But 
the extravasation may occur in a very different manner, affecting a 
great number of points at once, and having the appearance of a multi- 
tude of red dots scattered about, or of minute streaks. This is termed 
capillary apoplexy, to distinguish it from the other form ("apoplect. 
herd" of Rokitansky). It is often seen in the gray matter of the 
cerebral hemispheres after death, from concussion of the brain. 

If the hemorrhage, though taking place in the same way, be more 
abundant, the spots and streaks approach closer together, the tissue 
becomes more swollen, and, at last, may become thoroughly red, the 
blood having penetrated completely between and among the elements of 
the parts. Rokitansky enumerates the following exciting causes of 
hemorrhage: (1.) Hyperemia of very great intensity, of whatever kind. 
This may occur in various conditions of the system, but of course the 
local strain will be most severe when a state of plethora exists at the 
same time, and the action of the heart is powerful. We have seen 
considerable haemoptysis take place in a healthy person after very severe 
exertion. This might be considered as an instance of hemorrhage from 
intense active hyperemia. The large evacuations of blood that are 
poured out from haemorrhoids, exemplify the same result from passive 
hyperemia, as also do cases of passive menorrhagia. (2.) The hy- 
peremia that takes place in some kinds of inflammation which have 
been hence named hemorrhagic. This tendency is materially promoted 
by the delicacy and laxity of the tissue affected. The lungs are 
scarce ever inflamed without some amount of hemorrhagic exudation 
taking place, viz: the rusty sputa of pneumonia. Where scurvy is 
prevalent, hemorrhage seems more prone to accompany inflammations, 
as might, indeed, be expected. A form of pericarditis has recently been 
described by Dr. Kyber, which he terms "pericarditis scorbutica," in 
which, after death, large quantities of bloody coagula, together with 
effusions of lymph, are found in the serous cavity. Hemorrhage from 
this cause is apt to attack morbid growths, especially the softer varieties 
of cancer. (8.) The vessels may rupture and pour out blood in conse- 
quence of the tissue surrounding them becoming more spongy and lax, 
so that they are not adequately supported. This appears to be the cause 
of hemorrhage from the decrepit uterus of the aged. (4.) Textural 
disease of an organ, rendering it more brittle or soft than natural. The 
most marked instance of this is the fatty, degenerated heart, which has 
often undergone spontaneous rupture. (5.) Alterations of consistence 
of the coats of the vessels, such as take place in atheromatous disease 
or in chronic inflammation; this may affect the smallest vessels or the 
largest trunks, but is almost confined to the arteries, and may be ac- 
companied with dilatation (aneurismal) or not. (6.) Ulceration of the 
surrounding tissues may give rise to hemorrhage, by involving some of 
the vessels. Severe, or even fatal, hsematemesis, from ulcers of the 
walls of the stomach, is not uncommon. The hyperemia which issues 
in hemorrhage, may be occasioned by obstruction to the venous current, 
as in hemorrhoids from diseased liver, and pulmonary apoplexy from 



108 



HYPEREMIA. 



obstructive disease of the heart; or it may be caused by intense irrita- 
tion, as when bloody discharges are occasioned by drastic purgatives, 
or hematuria by stimulant diuretics. Posture may prove the cause of 
hemorrhage when the tonicity of the vessels is very low. Thus, stoop- 
ing has been known to occasion cerebral, and the erect posture uterine, 
hemorrhage. The influence of malaria and cold has been before noticed. 
There seems to be a kind of hemorrhagic diathesis; at least, Dr. Copland 
states that hemorrhages are more common in the oifspring of parents 
who have suffered from them than in others, and that the tendency is 
observed in several members of the same family. Hemorrhage from 
the rectum, urinary organs, and uterus, is said by Chomel to occur 
oftener in cold than in warm seasons, and epistaxis and haemoptysis to 
be more frequent in summer than in winter. Dr. Prout observed a 
peculiar tendency to renal hemorrhage during the time that cholera was 
prevalent. Age seems to have an influence in determining the seat of 
hemorrhage. Epistaxis is most common in children, haemoptysis in the 
early period of life, and hgemorrhoidal discharge in the aged. The 
blood, when effused, may remain in a liquid state for some time, or 
quickly coagulate. When it is poured out into the substance of a part, 
it undergoes, after a time, the changes which are commonly observed 
when a superficial part has been bruised. These consist in alteration 
of the color of the haematin, which passes "from a dark red into a blue, 
then into a brown, and lastly, into a yellow color, before it entirely 
disappears." At the same time the blood-globules, at least in many 
cases, undergo peculiar changes; they become massed together, and 
sometimes included in a kind of cellular envelop ; they waste and shrink 
up, until there remain at last only minute yellow or orange-red granules, 
which evidently consist chiefly of pigment. Such are not unfrequently 
found in the straight tubuli of kidneys affected with M. Brightii; they 
are the undoubted records of former hemorrhage. In some cases the 

Fig. 10. 




Haematin crystals. 



altered haematin takes the form of crystalloid, elongated, rectangular 
tablets, which vary very much in size, and are colored more or less 
deeply by red matter. The formation of these seems to be promoted 
by the addition of water. They were extremely well seen in a case 
which we witnessed of cystic disease of the kidney, in which several large 
dark clots were contained in a cyst of extraordinary magnitude. The 



HYPEREMIA. 109 

fibrin, and other residue of the extravasation, together with broken-up 
fragments of the tissue, are gradually reabsorbed, the solid substances 
undergoing liquefaction, chiefly in the way- of fatty transformation. A 
further change may take place, not so much in the effused blood, as in 
the parts around it. These, which are at first ragged and torn, undergo 
more or less inflammation, which ends in the effusion of a solidifying 
blastema; this fibrillates, and passes into the state of more or less perfect 
fibrous or areolar tissue, and thus forms a capsule or cyst, inclosing the 
now more or less altered blood. Rokitansky describes the cyst as being 
lined by a colored, soft, gelatinous, loosely-adherent layer, formed from 
the coagulum, which, at a later period, by fibrillating, and even develop- 
ing vessels, assumes very much the aspect of a delicate serous membrane. 
The contents of the cyst may be a gelatinous or serous fluid alone, or 
with more or less traces of a vascularized areolar tissue. In some cases 
absorption takes place completely, and the cavity is obliterated by the 
adhesion of the opposite sides, and the formation of a linear cicatrix. 
This, however, is not the most frequent issue, in consequence of the 
following impediments: (1) a large size of the cyst; (2) retraction of the 
surrounding tissue, depending partly on its atrophy, partly on its in- 
duration; (3) the deposition of the fibrin, either as a central lumpy mass, 
or as a thickish, peripheral, capsulating layer. The effused blood-mass 
may undergo a different kind of change, in consequence of absorption 
of its watery parts, and become, in this way, a kind of tumor, termed 
an hematoma. Dr. Walshe classes this along with other growths, but 
we think it better to consider it as a simple result of hemorrhage, and 
this for three reasons : (1) that it presents no higher structural character 
than that of fibrin; (2) that it is generally devoid of vessels; (3) that it 
does not appear to increase by growth in the proper sense of the term. 
Dr. Walshe describes an hematoma from the spinal meninges, which had 
been produced by a blow, as of the size of a walnut, of pale straw color, 
and of fine granular texture when closely inspected. "Such tumors 
exhibit, microscopically, the qualities of fibrin ; fibrils gelatinizing with 
acetic acid, amorphous fragments, granules, and molecules." "Their 
chemical relations are those of fibrin." An epithelial investment covers 
the surface, and makes it smooth, but there is usually no enveloping cyst. 
Haematomata occur in serous and synovial cavities, beneath fibrous and 
mucous membranes, in parenchymatous organs, in muscular masses of 
the limbs, in the substance of certain new products, especially encepha- 
loid cancers, in cavities accidentally formed in the tissues, as in tuber- 
culous cavities of the lungs. An hematoma thus formed, and being 
essentially a fibrinous mass, may undergo certain other changes; saline 
earthy matter may be deposited in it, inducing a state which is more 
correctly named cretification, than ossification ; melanic pigment may 
probably also form in it. It may, perhaps, undergo a development to 
the somewhat higher stage of fibrous tumor, and sometimes even true 
bone may be formed within it. A vascular plexus has been observed in 
several instances in tumors of this kind; and though it may be objected 
that this has been developed in superadded exudation-matter, yet it 
appears to us very much more probable that the persistent fibrin afforded 
the developmental nidus from its own substance. One result of hemor- 



110 FLUX AND DROPSY. 

rhage, even in lesser degrees, may be the persistent discoloration of 
the tissues from the presence of brown or black pigment, which is dif- 
fused among the elementary parts in a finely divided condition, as one 
of the transformations of the effused haematine. Hemorrhage, like the 
hyperemia from which it results, may be active or passive, sthenic or 
asthenic. The former variety is associated with the same general con- 
dition of the system which characterizes active hyperaemia, the latter, 
in the same way, is connected with passive hyperemia. Rokitansky 
says of the condition occasionally observed, in which hemorrhage takes 
place to an alarming amount, even from a slight cause, which he terms 
Haemorrhophily, that it depends, as far as we know at present, on an 
unusually delicate construction and vulnerability of the vascular mem- 
brane, together with a thin, watery quality of the blood in general. 



FLUX AND DROPSY. 

We have already in part noticed these results of hyperaemia, more 
particularly of the passive variety, but it seems desirable on account of 
their great importance and frequency to review them separately. The 
term flux may be properly applied to a discharge of various kinds taking 
place from a mucous surface, or from a glandular organ connected there- 
with ; the term dropsy to an effusion of fluid in serous or synovial cavi- 
ties, or in the areolar tissue. Fluxes will be active or passive according 
to the kind of hyperaemia which occasions them; the same can scarcely 
be said of dropsies; the very great majority of them are passive. It is 
necessary to fix some limitation to the kind of fluid that may be said to 
constitute flux or dropsy, as there are many exudations which require to 
be distinguished on account of their different nature. A sero- purulent 
effusion, on the secretion of a serous cyst, would not come under the 
present head. Perhaps we shall be nearly correct if we say that a fluid 
similar to, but more aqueous than the liquor sanguinis, mingled in the 
case of flux with a varying quantity of mucous secretion or desquamated 
epithelium, mature or immature, and if proceeding from a gland mingled 
with more or less of its secretion, is that which properly belongs to this 
kind of morbid action. 

Of active fluxes we have a good example in miniature in a common 
sneeze ; the peculiar sensation demanding the reflex expiratory contrac- 
tion is no doubt occasioned by the turgid state of the bloodvessels of the 
Schneiderian membrane pressing upon the interwoven nerves; this hy- 
peraemia quickly terminates in a muco-serous effusion which the blast 
expels, and after one or two such acts, all is quiet again. More con- 
siderable, and much more enduring is the hyperaemia in the state of 
coryza, and the serous flux is of course much more prolonged. In this 
instance we have an opportunity of observing a quality of the fluid of a 
serous flux which is very common, viz: that it is especially acrid and 
irritating, so that it will sometimes excoriate the parts over which it 
flows. What gives it this quality is not very apparent ; it seems at least 
doubtful whether it is merely an excess of the natural saline ingredients 
of the blood. We should rather suppose it to be some organic acid salt 



FLUX AND DROPSY. Ill 

of new formation. The fluid under the microscope exhibits very little 
trace of corpuscles, and is alkaline. 

Choleric diarrhoea is the extremest example of active morbid flux, the 
■whole blood seems to rush to the intestinal surface, and pour out its 
fluid part, minus the greater part of the albumen and fibrin. The gruel- 
like evacuations consist of water and saline matter, with some trace of 
albumen in solution, and a large quantity of columnar epithelium. 1 The 
reaction of the fluid is alkaline. The filtering action of the intestinal 
membrane in this instance is very marked, and well worth noticing ; it 
is, indeed, extraordinary, that, while so rapid a rush of blood is going 
on to the exhaling surface, the effused fluid should be so considerably 
altered from that which arrives thither; one would have expected it to 
contain at least as much albumen as the passive exudation of ascites. 
We would ask whether the case of choleric diarrhoea, as well as the 
similar condition from drastic purgatives, do not absolutely prove the 
existence of a power influencing the circulation other than the vis a tergo 
of the heart with the regulating contractility of the bloodvessels? Does 
it not also demonstrate that it is this nutrition force of the tissues, as 
we have called it, which determines whether an hypersemia shall issue 
in a flux or in an inflammation? In profuse salivation arising from the 
administration of mercury, or other causes, we have a good instance of 
an active flux, from a glandular organ, although the fluid is in this case 
almost identical with the natural secretion. It is not unfrequently ob- 
served, that if an active flux be suddenly checked, it will be transferred 
to some other part, where it may, perhaps, produce much more serious 
consequences. The part to which the metastasis takes place may be a 
solid organ, or a secreting surface ; in the first case dangerous hyper- 
semia, and possibly hemorrhage, may occur ; in the second, the hyper- 
semia will relieve itself by a free effusion of fluid. Thus arrest of the 
menstrual discharge by cold is often followed by determination of blood 
to the head, arrest of an habitual diarrhoea by the same result, or by 
the supervention of ascites. The characteristics generally of active 
fluxes are those of active hyperemia, which is more or less apparent 
according to the amount of the effused fluid : if this be considerable, the 
hypersemia is dissipated as fast as it arises. Active dropsies are often 
termed acute, or febrile, and are not always easily distinguished from 
inflammatory effusions. An almost certain means of distinction is, to 
observe whether the effused fluid is even slightly turbid with flakes of 
lymph, or puriform corpuscles; the presence of these is decisive of the 
inflammatory nature, or at least of some degree of coexisting inflamma- 
tion. Acute anasarca affords one of the best instances of active dropsy, 
the interruption of the action of the kidneys, at the same time that it 
deteriorates the quality of the blood, and renders it less fit to circulate 
in the vessels, diminishes considerably the separation of fluid from it, 
so that from both these causes there arises a tendency to the effusion of 
fluid in the areolar tissue, or in other parts. The tenseness and firmness 

1 In one case we examined, the gruel-like fluid contained feebly formed nuclear parti- 
cles, with a few granular globules and cells, and an abundance of granular matter ; there 
was little or no epithelium in the evacuations, and some was found in situ 38 hours after 
death. 



112 FLUX AND DROPSY. 

of the anasarcous swelling in many of these cases lead to the belief 
which direct observation has confirmed, that the effused fluid contains 
some amount of fibrin, which coagulates among the elementary parts of 
the tissue, and makes them more dense and stiff. The same thing occurs 
also in dropsies of serous cavities, and has been particularly noticed by 
Yogel, under the name of Hydrops Fibrinosus. 

Yogel does not seem to discriminate between fibrinous dropsy, result- 
ing from hyperemia, and that resulting from unequivocal inflammation ; 
and probably it is not necessary. The one condition is the inceptive 
of the other, and passes into it by imperceptible grades, or may exist 
in various degrees along with it. In fact, in this instance, and all 
through our study of pathological anatomy, we cannot too constantly 
bear in mind that, though we take, and are justified in taking, for de- 
scription, certain typical forms of living and acting, yet these are seldom 
rigidly defined, but pass easily into each other, or coexist in the same 
part variously combined. The simple unmixed case is the rare one, the 
multiple and the complex the common. Having premised thus that 
fibrinous dropsy may be, and often is, the result of an inflammatory 
process, as well as of an active hyperemia ; but regarding it as more 
properly the product of the latter than of the former, we proceed to 
follow the account given of it by the excellent pathologist just quoted. 
He remarks that " it may occur either in serous cavities (as in the pleura, 
arachnoid, peritoneum, or pericardium), or may collect in the paren- 
chyma of organs." In both cases, however, it is essentially similar. 
" Examined immediately on its discharge, the fluid resembles in all 
points that of serous dropsy. This either is perfectly clear and color- 
less, or else more or less turbid, opalescent, and of a greenish, yellow 
color ; and, examined microscopically in its recent condition, exhibits 
either no solid particles" (the case of pure hypersemia), "or only such 
as may be accidentally present, as occasionally minute amorphous coagula 
of fibrin, pus-corpuscles," &c. (inflammatory complication). " Some time 
after its discharge, the whole fluid generally coagulates, in consequence 
of holding fibrin in solution, and forms a homogeneous, tremulous jelly, 
which, after standing for some time, separates into a partially consistent 
colorless, or reddish-yellow clot of coagulated fibrin, and a clear yellow 
fluid, analogous to the serum of the blood." " The coagulated fibrin 
appears under the microscope as a perfectly amorphous mass, and devoid 
of any traces of cellular structure." The effused fluid bears a pretty 
close resemblance to the liquor sanguinis, containing the same saline 
and animal matters, but a less proportion of albumen and fibrin. Yogel 
considers that the effusion of fibrinous fluid depends on the transudation 
taking place through the walls of the capillaries, while a simply serous 
effusion is poured out through the walls of the veins. We cannot join 
in this view, as it seems to us impossible that transudation should take 
place in any case exclusively from the one or from the other. All the 
capillaries and minute veins in hypersemia are alike gorged, and there 
is no sufficient difference in the structure of their coats to make it proba- 
ble that they affect at all materially the nature of the exudation. The 
real cause of the difference between fibrinous and serous dropsy we 
believe to be the different quality of the blood, the existence of a differ- 



FLUX AND DKOPSY. 113 

ent crasis, to use Rokitansky's term ; in fact, the presence of a greater 
amount of fibrin. Vogel recognizes the dependence of fibrinous dropsy 
on dynamic causes; i. e. its association with active hypersemia, "while 
serous dropsy depends more upon mechanical. This is true; but at the 
same time we have seen some amount of fibrinous effusion occur in pas- 
sive dropsy, depending upon mechanical obstruction to the circulation. 
The fibrin contained in the fluid may either remain for a long time (days, 
or even weeks) within the body uncoagulated, and coagulate after its 
discharge, or it may pass at once, while within the system, into the 
coagulated condition. It may also serve as a blastema for organic for- 
mations. This we shall speak of further on, under the head of " Exu- 
dations." 

Passive fluxes are of extreme frequency, and are almost invariably 
associated with debility. Their copiousness, the aqueous nature of the 
fluid, the frequent pallor, and non-elevated temperature of the parts 
from whence they proceed, as well as relaxed conditions of these, may 
be said to be their general characters. They take place, as is mani- 
fest, from mucous surfaces, or from the glands that open upon them, 
and are, in consequence, mingled, more or less, with liquor muci, 
and with epithelial particles, in various stages of formation. In some 
cases, as in bronchorrhose, occasionally they may depend upon venous 
obstruction ; but their most essential cause seems to be a peculiarly re- 
laxed and toneless state of the walls of the vessels, and of the tissues 
affected. This is confirmed by the beneficial effect of astringents, locally 
applied. At the same time, there is no doubt that the state of the blood, 
and of the system generally, has an influence upon them, and that, as 
the quality (the crasis) of the former is improved, so the debilitating 
profluvium will diminish. It is reasonable to suppose that in this way 
the walls of the vessels are brought into a condition of more healthy 
tone. The peculiar condition of the tissues, as to their vital endow- 
ments, seems to be the only sufficient cause to which we can at all ascribe 
the different phenomena exhibited by the same tissues, under similar 
circumstances. One person shall have a chronic bronchitis, with puri- 
form expectoration, while another person is suffering under bronchor- 
rhcea, although the circumstances may be similar, and the two affections 
very much alike in their outset. When we speak of a toneless and 
relaxed condition of the vessels being the main cause of the flux, we do 
not so much mean to imply a defect in their contractile power (though 
this doubtless exists), but rather such an alteration of their texture, as 
that they are much more transudable by the aqueous part of the blood 
than is normally the case. In health, a certain slight exudation takes 
place from the capillaries, and all the minuter vessels, forming a nutrient 
atmosphere, in which the tissues are bathed. The exact composition of 
this is uncertain ; but, as the following experiment shows, it probably 
contains less albumen and fibrin than the liq. sanguinis. Valentin, hav- 
ing made an albuminous solution of a certain specific gravity, placed it 
on a filter of stretched serous membrane, and, on examining the fluid 
which passed through, he found its specific gravity reduced; that is to 
say, some of the albumen was left behind. It is probable, and seems 
proved by pathological experience, that increase of the pressure upon 



114 FLUX AND DROPSY. 

the fluid causes it to transude in a less altered state; so that this, 
whether it he a vis a tergo, from increased cardiac impulse, or caused 
by an obstruction in the onward direction, must be one cause of an effu- 
sion containing much albumen and fibrin also. But the common watery 
and mucous effusions, which constitute such fluxes as those of leucorrhoea 
and bronchorrhcea, contain little, if any, albumen, and no fibrin, and 
are chiefly remarkable by the quantity of their aqueous and saline con- 
tents. The same may be said also of the intestinal and cutaneous 
fluxes that take place in phthisis, and in other exhausting diseases. 1 In 
all these it seems certain that the natural filtering power of the walls of 
the vessels is changed in such a way that they allow the aqueous and 
saline part of the blood to transude with extreme rapidity. At the same 
time, the crasis of the blood itself is altered; it turns, as the popular 
phrase is, to water; i. e. its corpuscles and its organic matters are not 
formed in due proportion, but, on the contrary, waste and diminish, so 
that the colliquative discharges from the tissues are promoted, and kept 
up by the (as it were) deliquescing blood. It is interesting to observe 
that the filtrating property of the vascular membrane is capable of being 
influenced through the nervous system. Thus, after a fit of hysteria, a 
quantity of limpid aqueous urine is passed, much more than would have 
been voided had no such event occurred. This must depend upon an 
alteration of the condition of the Malpighian tufts, and perhaps of the 
capillaries of the tubular venous plexus. We have noticed something of 
the same kind after a small dose of opium. Almost the only instances 
of fluxes taking place from the glands, with which we are acquainted, 
are those which the kidneys afford. That of diabetes depends, as is well 
known, upon a diuretic substance, sugar, circulating in the blood, and not 
undergoing the decomposition which it should normally. Diabetes insi- 
pidus was believed, until recently, to depend upon some other and dif- 
ferent cause; but it has been shown by Thenard and others that the 
only difference is that the sugar which is present, and produces the 
diuretic effect, is tasteless. In cases of polydipsia, where an excessive 
quantity of urine is passed, of low specific gravity, the flux depends 
simply on the injection of an undue quantity of liquid, in consequence 
of extreme thirst. Discharges, such as those of chronic bronchitis, or 
chronic dysentery, which were, in their commencement, of truly inflam- 
matory nature, but afterwards become more of the nature of fluxes, 
often contain a very large amount of muco-purulent matter, and cause 
a proportionally severe drain on the system. These, however, do not 
present the hydrsemic condition of the general system, before alluded to. 
Passive dropsies are the commonest of all ; all the cardiac dropsies, 
and most of the renal that we meet with, are of this kind. Their very 
aspect excludes the idea of increased action (however the term may be 
understood), and naturally suggests that of some obstruction to the cir- 
culation, with diminution of the vital energies. The surface is generally 
pallid, or of a dull venous hue, the animal heat is diminished, the ana- 
sarcous swellings pit easily on pressure, the effect of gravity upon them 

1 Simon states that he failed in detecting any certain indications of albumen in the 
sweat collected (by means of linen washed with distilled water) from the breast of a 
person in the colliquative stage of tubercular phthisis. 



FLUX AND DROPSY. 115 

is marked, the movements are languid, the respiration often embar- 
rassed, and the mind depressed. The character of debility is strongly 
impressed upon them, and there is much correctness in the common 
feeling, that when dropsy appears, it announces the approach of decay, 
and of the breaking up of the system as it is called. One of their most 
common, but as we shall see, probably, not their immediate cause, at 
least in many instances, is, beyond doubt, a mechanical impediment to 
the free course of the blood. This was long ago proved by the well- 
known experiment of Lower. He tied the jugular vein of a dog, and 
found that all the tissues of the head and face were infiltrated after the 
lapse of some hours, not with extravasated blood, as he had rather 
expected, but with clear serum. The analogous instance of ascites 
resulting from cirrhosis of the liver has been already mentioned. But 
it requires no very long pathological experience to discover that there 
are cases not unfrequently occurring, in which, although there exist 
abundant causes of obstruction to the circulation, yet dropsy does not 
take place. Dr. Walshe, in his work on diseases of the lungs and 
heart, p. 478, has given a list of most serious diseased conditions of the 
heart which may exist without producing dropsy, and concludes justly, 
that something beyond all these is wanting to insure this occurrence. 
What, then, is this ? Andral shows, in his Hematologic, that neither 
diminution of the globules, nor of the fibrin of the blood, is the imme- 
diate cause of dropsy, but, that this always accompanies a diminution 
of the albumen. It is, therefore, highly probable that it is this altera- 
tion of the crasis of the blood which determines the occurrence of dropsy 
in persons who are predisposed to it by organic disease of the heart or 
lungs, which causes congestion of the venous system. It is not only in 
dropsies of cardiac origin that diminution of the albumen seems to be 
the most important moment 1 in producing the effusion. This cause is 
evidently influential in renal dropsy, in which a constant drain of albu- 
minous serum out of the blood is taking place. It is remarkable that 
this may have been going on for some, perhaps a considerable time, and 
yet no dropsy occur. The explanation of this is afforded by the cir- 
cumstance ascertained by Simon and Christison, that the decrease of 
the solid constituents of the serum is not always the leading character 
in this disease. In three of Simon's analyses out of four of blood in 
Bright's disease, the quantity of albumen was decidedly increased — in 
one instance amounting to 109.4, considerably above the average of 
health. Cases of dropsy occasionally are met with, in which, as there 
appears no absolute organic disease, but only an hydremic condition of 
the blood, one is obliged to conclude that the effusion is dependent on 
this. A female is now under our observation, in St. Mary's Hospital, 
who has considerable anasarca of the legs and feet, with puffed eyelids, 
without any discoverable albuminuria, or disease of the heart. Andral 
mentions that, during a famine, where the poorer classes had been 
obliged to seek a scanty nourishment in roots and herbs growing in the 
fields, many persons became dropsical. In this, and similar recorded 

1 We ask leave to introduce this word as a convenient term, signifying an influential 
condition. 



116 FLUX AND DROPSY. 

instances, it is very probable that the proportion of albumen in the 
blood was diminished, as it is clear that the supply of it ordinarily 
derived from the food was so. When, from cardiac or renal causes, or 
both combined, together with altered crasis of the blood, the tendency 
to dropsical effusion is very strong, it is quite remarkable how universal 
the dropsy becomes; the peritoneum, both pleurse, and the pericardium, 
may be found full of fluid, the areolar texture everywhere infiltrated, 
the air-cells of the lungs loaded with frothy serum, the tissue of the 
brain " wet," and the subarachnoid fluid considerably increased. In 
fact, it seems as if the vessels no longer presented any containing 
barrier, but permitted the escape of fluid in every part that it traversed. 
It is often observable in these cases after death how the naturally 
transparent serous membranes have lost this appearance ; they look 
thickened, of a dull, white gray tint, as it were sodden in the fluid. 
There can be no doubt that this depends on a chronic thickening and 
increase of their fibrous layer. 

We have next to examine the composition of dropsical effusions; this 
generally approaches more or less closely to that of the serum of the 
blood. The purer fluids are clear, tolerably limpid, and colorless ; 
often, however, a marked yellow tint is observed, which may either 
arise from dissolved hsematin, or from the presence of an increased 
quantity of the natural yellow pigment of the serum; or again, especially 
in the case of ascites, from dissolved bile pigment. If the latter is the 
case, it will be rendered evident by the reaction with nitric acid. " A 
large quantity of albumen (Vogel says) renders it (the effused fluid) 
viscid ; a very large quantity, above twelve per cent., renders it thick, 
tenacious, and capable of being drawn out in threads, like albumen 
itself." A milk-white turbidity is occasionally observed, which depends 
on the admixture of fat (oil), or epithelium scales. Blood-globules may 
be often seen in great numbers in the fluid of ascites by the aid of the 
microscope : cholesterin tablets are common in that of hydrocele, and 
may be sufficiently numerous to constitute a crystalline deposit. The 
reaction of the fluid is alkaline ; in rare instances an acid has been 
observed; in Vogel's opinion, probably from the presence of lactic. 
We subjoin, from the same author, the results of seven analyses, which 
show some remarkable variations in the amount of the several con- 
stituents. 

3 

927 
48 

10 l 

6 X 'l 1} 10 -° 4 

Blood Serum. Hydrocele. Hydrocele. Ascites. Ascites. Ascites. Ascites. 

The seventh analysis shows actually a larger amount of albumen than 
is present in the serum of the blood ; this might be supposed to be an 
error if other similar instances had not been observed ; it probably de- 
pends upon a quantity of the water of the original effusion having been 
removed by absorption, so that the fluid became more concentrated. 
Urea has frequently been found in dropsical fluids ; its quantity is some- 
times very small, sometimes amounts to 6 parts per 1000. 



1 


2 


Water . . . 905.0 


920.0 


Albumen . . 78.0 \ 
Extractive matter 4.2 j 


71.5 


Fat ... . 3.8 




Salts ... 9.0 


8.5 



4 


5 


6 


7 


946 


956 


988.0 


704 


33 


29 


0.9 


290 


1.Q 


9 




2 



INFLAMMATION. 117 

This seems to be the most proper place to introduce a short notice of 
certain gaseous effusions which there is good evidence to show take place 
occasionally in different parts of the body. To them the name of Pneu- 
matoses has been given by Frank and others. Frank gives cases to 
prove that the subcutaneous cellular membrane, when slightly inflamed, 
may secrete air in abundance, and thus give rise to emphysema. The 
same has been observed after attacks of profuse hemorrhage during life, 1 
and we are convinced we have witnessed something of the same kind 
in post-mortem examinations when there was no trace of putrefactive 
change. Dr. Graves, whose interesting article on the subject we need 
only refer to, mentions a case quite conclusive, as we think, of the 
secretion of gas to a considerable amount in the cavity of the pleura, 
and we have ourselves observed a somewhat similar occurrence. In the 
post-mortem examination of a female, who died with extensive bed-sores, 
after symptoms of fever, the right lung was found compressed against 
the Y. column, and bound down by layers of false membrane, which also 
formed bands crossing the pleural cavity. This w T as empty of fluid, but 
must have been filled by air, as a very considerable space intervened 
between the lung and the wall of the thorax. No vomica was found in 
the lung, or any evidence of rupture of the pleura. The peritoneal 
cavity seems also to be the seat of gaseous accumulation in rare in- 
stances. The development of gas in great abundance from the mucous 
membrane of the stomach and intestines is a phenomenon of daily and 
troublesome experience ; we speak now of an actual secretion from the 
mucous surface itself, and not of the result of decomposition of ingesta. 
The influence of certain states of the nervous system upon the develop- 
ment of gas is often evidenced in hysteric and emotional excitement, 
and also by the circumstance which we have observed, that it will take 
place, sometimes, very rapidly from the stomach after an action of the 
bowels. The accumulation of gas is sometimes so considerable as 
to produce alarming or very distressing symptoms ; we have seen it 
even, in a minor degree, induce or aggravate attacks resembling angina 
pectoris. 

A very remarkable case has been recorded by Sir F. Smith, of ex- 
cessive development of gas from the stomach, also from the urinary 
bladder, and from the surface of the skin. Respecting the cause and 
mode of production of these pneumatoses we are totally ignorant, but 
the fact of their occurrence is most important in its relation both to 
practice and science. 



INFLAMMATION. 

"We proceed, according to our plan, to the third variety of hyperemia, 
that in which the movement of the blood in the part affected is partly 
increased, partly diminished. The truth of this definition, so far as it 
goes (though we believe it to be a very imperfect one), is shown — 1st, 

1 A portion of the liver of a man, who died suddenly with aneurism of the left carotid, 
became so full of gas about two days after death, that it floated on the surface of water. 
Portions of the heart and kidney were not thus affected ; they sank in water. 



118 INFLAMMATION. 

as to the increased motion by Mr. Laurence's well-known experiment of 
drawing blood at the same time from an inflamed and from a healthy 
arm of the same patient, when three times the quantity of blood flowed 
from the vein of the inflamed as from that of the healthy limb; and, 
2d, as to the diminished motion, by looking at an inflamed part through 
a microscope when the arrest, or stasis, as it is called, of the blood cur- 
rent in the affected part is most evident. 

The general appearance of an inflamed part is well described in the 
terms handed down from the age of Celsus, as being the seat of redness, 
heat, pain, and swelling. These are the visible symptoms of a patho- 
logical process, which, though continually before our eyes, and of the 
utmost importance in its results, and though it has been the subject of 
numberless speculations and careful labors, we are compelled to ac- 
knowledge we are still imperfectly acquainted with. The redness of an 
inflamed part is more or less vivid ; it is deepest in the centre, and 
gradually shades off towards the circumference ; in this respect it dif- 
fers from an extravasation whose margin is more defined, as also in the 
circumstance that it can be in a greater degree removed by pressure, 
though by no means completely. The aspect of the redness may differ 
according to various circumstances ; if the capillary networks of the 
part affected be a plane, or uniformly extended, the injection will appear 
as an uniform deep blush ; if, on the other hand, they are moulded to 
the form of villi, or folds of mucous membrane, the surface will have 
the appearance of a pile of red velvet : in fibrous structures a streaky 
appearance is observed, and generally the form of the redness will de- 
pend upon the arrangement of the capillaries of the part. The increased 
depth of color is owing chiefly to distension of existing vessels, not in 
anywise to the formation of new ones, a process which does not take 
place till a much later period : the only other cause which at present 
exists is the staining of the surrounding tissues with exuded hsematin, 
which may occur soon after stasis has been established. It is necessary 
to distinguish carefully between genuine inflammatory redness, and 
that which often simulates it closely in the dead body, viz : hypostatic, 
or depending solely on mechanical causes, or on the mode in which 
death has taken place. It is always desirable to take other circum- 
stances into consideration at the same time, but we may generally say 
that we should suspect the inflammatory nature of a redness which ex- 
isted solely in depending parts, or in those the large veins of which 
were much gorged, or which coincided with a fluid condition of the 
blood, and which was not attended with any thickening of the part. 
It may also be observed, that after an internal part has been exposed 
to the air a short time, it assumes a much more marked and brighter 
redness, which depends solely on the action of the oxygen in the air. 

The natural temperature of an inflamed part seems to be considerably 
increased, and this as well to the sensations of the observer as of the 
sufferer (hence the name "inflammatio," a burning). An increase of 
heat is, however, not so decidedly shown by the thermometer; in some 
of Hunter's experiments the difference was not more than 1°, and it 
seems doubtful whether the heat of the inflamed part is ever greater 
than that of other parts of the body. The highest temperature we find 



INFLAMMATION. 119 

mentioned is HOf ; this was in tetanus, which is not an inflammatory 
disease. Rokitansky says, that the increased temperature in inflamma- 
tion is partly occasioned by the formative processes which take place in 
the stagnating blood, but that a very important part in the phenomena 
is also played by the excitation of the sensitive nerves. It is this nervous 
excitement, doubtless, which gives rise to the idea of the great increase 
of temperature. The pain of inflammation varies much in degree and 
in kind, according to its seat, and intensity, and exciting cause. That 
of inflamed serous membranes is often of a peculiar, sharp, darting kind; 
that of mucous membranes more dull and gravative, as it is termed; that 
of dense, unyielding, fibrous or bony textures, amounts sometimes to 
extreme agony. The inflammation heightens the sensibility of the nerves, 
which are at the same time compressed by the swollen textures and dis- 
tended vessels. 

Swelling depends manifestly in great measure upon the distension of 
the vessels with blood; the bulk of the part is increased just as that of 
a kidney or liver is when it is injected artificially — its fibres are put on 
the stretch, its vessels strained, and its capsule, if it have one, fully dis- 
tended. The effusion of plasma is considered by Rokitansky as the 
principal cause of the swelling; this may be the case at a later period, 
and in some cases, but is not, we think, so powerful a cause as the vas- 
cular injection. In loose textures it will be more considerable than in 
denser. 

We now proceed to the more minute examination of the phenomena 
of the inflammatory process as they have been disclosed to us by the 
microscope, and we here resume the line of inquiry which we commenced 
during our consideration of active hyperemia. We saw in this, that, 
with a certain amount of stimulation, the arteries enlarged, and admitted 
a greater quantity of blood, which flowed on more rapidly, and traversed 
with an accelerated current the capillaries and veins which became 
dilated also. An increased and more rapid blood-flow were then the 
characters of determination of blood. But if the stimulus is increased, 
or if it be excessive from the first, phenomena of a very different kind 
present themselves. The current slackens, it moves slower and slower, 
and at last ceases ; the capillaries are seen distended with a red uniform 
mass, the veins are also enlarged, and filled with red corpuscles, crowded 
together, which retain more of their distinct form than those in the 
capillaries, and move either slowly onwards, or oscillate, or are quite 
stagnant ; the arteries, which are also distended, exhibit for some time 
a progressive movement onward of their contents, which at first is steady, 
afterwards becomes jerky, or intermittent, and at last ceases. The 
condition of stasis, as it is called (loTtipi, to stand), is now established, 
and therewith, as the sequence of active hyperemia, inflammation. In 
the immediate neighborhood of the seat of stagnation the circulation is 
still seen going on rapidly, and not only in the parts adjoining on the 
margins of the stasis, but even within its area capillary streams may be 
seen here and there rapidly coursing beneath a plexus of channels, which 
are filled by an uniformly red quiescent mass. Manifestly, determina- 
tion of blood prevails actively all round the focus of arrest of movement. 
The stagnant blood in most of the capillaries presents an uniform red 



120 



INFLAMMATION, 



mass, in which the separate corpuscles are undistinguishable ; here and 
there gaps may be seen, as if a fissure had taken place, and separated 
the adjacent portions a little away from each other. Amid the mass of 
blood-globules, appearing as it were fixed together, may be seen occa- 
sionally one or two white corpuscles ; according to our observation, they 
are certainly not to be seen in the great majority of capillary vessels. 
After the stasis has existed some time, they may be seen in great num- 
bers coating the walls of the veins, and rolled along by the current 
passing through them ; and occasionally they constitute, together with 
transparent plasma, the entire contents of a portion of vessel of some 
length, not remaining absolutely stagnant, but oscillating to and fro, or 
moving sometimes slowly onwards. From a vessel thus filled we have 
observed them escaping into a communicating vein, three or four at a 
time, and carried away into the general circulation. The diameter of 
the distended capillaries, which are the seat of stasis, has appeared to 
us, for the most part, tolerably uniform, but in one instance we observed 
numerous constrictions at various points. These were remarkably abrupt, 
and extended across one-third, or one-half, the channel. Mr. Wharton 

Fig. 11. 




Colorless globules adherent. 6. Blood-disks, still circulating, c. Dense, stagnant, homogeneous mass. 
d. Corpuscles in oscillatory movement, becoming detached from the impacted mass. — Williams. 



Jones mentions a local dilatation of arteries, but we find no account of 
these local contractions of the capillaries. The red globules, for the 
most part, appear to be packed together without any regular arrange- 
ment, but occasionally they may be seen lying together in rouleaux, 



INFLAMMATION. 



121 



like the corpuscles of human blood, with their long diameter transverse 
to the axis of the vessel. The white corpuscles are not unfrequently 
seen of a pyriform shape, dragging slowly along, or actually sticking 
to the sides of the vessels ; that they do possess some degree of adhe- 
siveness is manifest, but it does not seem to be so considerable or general 
as Dr. Williams supposes. When the inflammation is subsiding, and the 
stagnant blood beginning again to resume its course, all that can be 
observed is, that the agglomerated mass of red corpuscles in a vessel 
loosens and breaks up, so that the individual corpuscles are again visible, 
while the impulse of the heart makes itself more and more felt, and at 
last sweeps away the accumulation altogether, having first detached 
small portions successively. Fibrinous coagula also form occasionally, 
as Mr. Wharton Jones describes, and are similarly disintegrated, and 
carried away by the returning current during resolution of the inflam- 
mation. While stagnation continues, a small quantity of hsematin dis- 
solved in the serum exudes, and imparts to the tissues bordering the 
vessels some degree of yellow staining. 

We intend the foregoing account to serve as a description of what may 

Fig. 12. 




An exact copy of a portion of the web in the foot of a young frog, after a drop of strong alcohol had hee n 
placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus ; the intermediate or 
capillary plexus running OTer them, and pigment-cells of various sizes scattered over the whole. On the left 
of the figure, the circulation is still active and natural. About the middle it is more slow, the column of blood 
is oscillating, and the corpuscles crowded together. On the right, congestion, followed by exudation, has 
taken place, constituting inflammatory action in the part. 

a. A deep-seated vein, partially out of focus. The current of blood is of a deeper color, and not so rapid as 
that in the artery. It is running in the opposite direction. The lymph-space on each side, filled with slightly 
yellowish blood-plasma, is very apparent, containing a number of colorless corpuscles, clinging to or slowly 
moving along the sides of the vessel. 

6. A deep-seated artery, out of focus, the rapid current of blood allowing nothing to be perceived but a red- 
dish-yellow broad streak, with lighter spaces at the sides. 

Opposite c, laceration of a capillary vessel has produced an extravasation of blood, which resembles a 
brownish-red spot. 

At d, congestion has occurred, and the blood-corpuscles are apparently merged into- one semitransparent, 
reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker 
and less transparent, partly by the action of the alcohol, partly by the exudation. This latter entirely fills 
up the spaces, or only coats the vessel. — Bennett. 



122 INFLAMMATION. 

be actually observed of the process of inflammation, as it occurs in the 
frog's web. Most of the statements we have verified by our own exa- 
mination, and we believe they are in accordance with those of the best 
observers. The question now presents itself, what occasions the stasis? 
and this is, in fact, the great and unsolved problem of inflammation. 
The earlier speculations as to the vessels being in a state of spasm, or, 
on the other hand, of atony, need not occupy our attention ; nor can 
we see that any definite ground is gained by the hypothesis of Hunter, 
that the vessels are in a state of active dilatation, except that he seems 
thereby to recognize the true nature of active hyperemia. Three 
opinions, of later date, may be said to be still sub judice. Two of them 
we have already referred to, when speaking of active hyperemia. The 
third is that maintained by Dr. Williams. He considers " that an 
essential part of inflammation is the production of numerous white glo- 
bules in the inflamed vessels ; and that the obstruction of these vessels 
is mainly due to the adhesive properties of these globules." With regard 
to this doctrine, a reference to the description we have given will show 
that we agree with Professor Paget and Mr. Wharton Jones, in reject- 
ing it. Nothing can be more evident, we think, than that the white 
corpuscles play no important part in causing the stagnation of the blood- 
current. But we differ from Mr. Paget, and agree with Rokitansky 
and Williams, as to the increased production of white corpuscles in the 
inflamed vessels. The numbers which present themselves in some of the 
small veins, cannot, we think, be brought together merely by accumula- 
tion, especially when we consider that most of the communicating 
capillaries are plugged up, and that they cannot therefore be trans- 
mitted from them. The neuro-pathological theory of Henle is the one 
which Rokitansky prefers ; but he acknowledges that it gives no satis- 
factory explanation of stasis of the blood. Henle himself thinks he can 
account for it according to his view as follows :' " As a physical conse- 
quence of dilatation of the vessels, there takes place a retarded flow of 
blood. This, together with the relaxation and dilatation of the vessels, 
favors the exudation of serum ; the consequence of which is, that the 
plasma of the blood in the part becomes inspissated by a preponderance 
of protein matter over the salts. This inspissation of the plasma de- 
termines endosmotic changes in the red corpuscle, in consequence of 
which they are disposed to aggregate." Rokitansky, stating that mere 
paralysis and dilatation of the vessels cannot give rise to stasis, gives 
the following as his own opinion of its mode of production : " It pro- 
ceeds (a) from the sticking together of the blood-corpuscles, the heaping 
up and wedging together of them in the capillaries, while the plasma 
in part flows off towards the veins ; (b) from the inspissation of the 
plasma occasioned by the exudation of serum through the dilated and 
attenuated walls of the vessels, and its saturation with fibrin and albu- 
men; (c) from the heaping up of the colorless corpuscles — i. e. nuclear 
and cell- formations, together with blood-globules; from their sticking 
together, and from the delicate, hyaline, fibrinous coagula, which 
develop themselves among them. This is certainly the most important 

1 Wharton Jones's Report on Inflammation, April, 1844. 



INFLAMMATION. 123 

moment in the inflammatory process, since, on the one hand, it very spe- 
cially throws light upon the phenomenon of stasis, and, on the other hand, 
comprehends also the plastic processes which take place in the heaped 
up and stagnant blood. It separates in this way the process of inflam- 
mation from a merely simple one of exudation. The elementary forma- 
tions above mentioned are not merely swept together towards the demesne 
of the stasis, but they originate as new (productions) in the stagnant 

blood, for this generally presents remarkable alterations " 

We believe the latter paragraph to contain views of very great import- 
ance, especially with regard to the effects of local inflammation upon 
the system. Nor do we doubt that the changes wrought by exudation, 
draining away of Liq. Sanguinis, multiplication of white corpuscles, 
and coagulation of the fibrin, may all exercise considerable influence in 
prolonging and confirming the stasis, and determining its results. But 
we do not think they are the primary and causative phenomena. It 
seems to us a very important fact, which Mr. Wharton Jones states, 
and which we have observed ourselves, that "stagnation commences in 
the capillaries, and extends from them to the veins on the one hand, 

Fig. 13. 

'.._ £=„ 




Production of stasis from Mr. Wharton Jones's Essay, Guy's Hospital Reports, vol. vi. p. 35. 

and the arteries on the other." We have seen the blood stagnant in 
the capillaries, while it was moving on steadily through an adjacent 
artery and vein. This points to the capillaries as the part where the 
arrest commences. Again, it is a very important circumstance, that, if 
a strong stimulus be applied, the stasis takes place almost immediately: 
it seems as if the blood were suddenly coagulated in the capillaries. 
When the arrest comes to pass more slowly, so as to admit of being 
watched, it is described by Mr. Wharton Jones as taking place in the 
following way: Red corpuscles, more collapsed and darker-looking than 
natural, first adhere to the walls of the vessels, and then other red cor- 
puscles adhere to them. "The first adhesion of red corpuscles to the 
wall of a vessel usually takes place at a bifurcation, and in this manner 
(see Fig. 6) : The stream c, striking with force on the wall of the vessel, 
at the bifurcation A, some of the red corpuscles adhere to the wall of 
the vessel. Other red corpuscles adhering to them, an agglomerated 
mass results, which is sometimes seen to be moved along the vessel a 
short way by the force from behind ; but more red corpuscles adhering 



124 INFLAMMATION. 

to the mass, the vessel is at last wholly blocked up by it at D. The 
stream c, being no longer permitted to pass in part by d, passes off by 
E ; but in leaving E, the stream strikes on the wall of the vessel at the 
bifurcation B, where red corpuscles adhere, and form a nucleus for an. 
agglomeration, which blocks up both the vessels F and G — e and o also 
becoming blocked up, and so on the process goes. Stagnation is seen 
first to take place in those capillaries which are least in the direct 
course from the artery to the vein. In those capillaries which lead 
most directly from the artery to the vein, and in which, consequently, 
vis a tergo operates most advantageously, the blood is latest in stagnat- 
ing." The main point, that stasis is produced by the red corpuscles 
adhering to the walls of the vessels and to each other, is confirmed by 
others, and by our own observation. On one occasion, we distinctly 
noticed a single red corpuscle adhering, by one end, to the wall of a 
vessel, in which circulation was returning, while several other red cor- 
puscles, in motion one after another, swept slowly past, brushing against 
it, as it waved in the current. That in the healthy state the red cor- 
puscles pass on so smoothly and uninterruptedly within their even rela- 
tively narrow channels, that they shun, as is well known, the walls, and 
allow a thin layer of the fluid in which they float to intervene, while the 
colorless corpuscles show no such tendency, but affect a preference for 
the so-called still layer, and move slowly onwards in it; that there is 
decidedly a tendency of the red globules to aggregate together in blood 
drawn from the body, while this seems to be held in abeyance, while 
the blood is within the vessels ; that the smallest capillaries, according 
to Wharton Jones, are traversed chiefly by plasma, and by a few color- 
less corpuscles, one after the other, with only a single red corpuscle 
now and then ; that the red and colorless corpuscles show no tendency 
to stick together, appear to us very significant facts, which require 
some such hypothesis as that offered in Wharton Jones's report, April, 
1844, viz : " That there exists some sort of attraction between the 
colorless corpuscles and the walls of the vessels, but an absence of 
attraction, if not a repulsion, between the red corpuscles and their walls, 
as also between the red and colorless corpuscles." Mr. Wharton Jones 
formerly conceived that it was the nervous influence which prevented 
the red corpuscles from aggregating together within the vessels, as they 
do out of the body, and that stasis depended on the suspension of this 
influence. It was an ingenious and probable opinion, but is disproved 
by the experiments which he himself has performed, and which are 
related in the Astley Cooper Prize Essay. In these he shows, that, 
after the nerve accompanying an artery had been divided, the flow of 
blood, though interrupted for a short time, soon returned, and became 
quite free; and also that, after section of the ischiatic nerve, the arte- 
ries of the web of the same side are found somewhat more dilated, and 
the flow of blood in them freer and more rapid than in the web of the 
uninjured side, while stagnation was induced more readily in the web 
of the limb whose nerves were entire, than in that of the limb whose 
nerves had been divided. He now adopts the opinion of Henle, though 
somewhat modified, that stagnation depends on inspissation of the 
plasma, on its containing an increased quantity of fibrin and albumen, 



INFLAMMATION. 125 

and rests much on the fact that such a condition of the Liq. Sanguinis, 
whether natural or imitated artificially, is found to increase the ten- 
dency of the red corpuscles to aggregate together. Our limits forbid 
discussion ; and we therefore simply pass on to state our own opinion, 
so far as we may venture to offer one on this qucestio vexata. We saw 
reason to believe that the tissues, in virtue of their nutrition power, 
exercised an influence on the movement of the blood ; that in active 
hyperemia their attractive force was increased; and we would now 
add, that it is through the failure of this nutrition power that we be- 
lieve stagnation takes place. The exact nature of the influence exer- 
cised by the tissues over the blood, which traverses the capillary chan- 
nels, is unknown. All that we can discern is, that it is such as pro- 
motes its free passage through them ; and therefore, when it is in 
abeyance or greatly altered, it is to be expected that the circulation 
will be interrupted also. More than this we cannot gather from the 
observed phenomena; and we would only offer the remark, in conclu- 
sion, that in coincidence with the establishment of complete stasis, 
cessation of the natural function of the part occurs, and other pro- 
cesses commence — the exudative, in which the plasma, that in a healthy 
state would have ministered to and maintained healthy action, is con- 
sumed in wasteful or even destructive changes. Whether the stasis 
depend solely on a persistence and exaggeration of the attraction of 
the tissues for the blood which exists in active hyperemia, or upon this 
and an abolition of the natural non-aggregative tendency, or even re- 
pulsive tendency of the red corpuscles for each other and for the walls 
of the vessels, must remain uncertain ; but the coincidence above no- 
ticed must be allowed to give considerable support to the main point, 
on which we would insist, viz: that the nutrition power of the tissues 
is chiefly concerned in the production of the flow of active hyperemia, 
and tbe stasis of inflammation. 

We must take some notice of the different varieties of inflammation, 
which depend, partly on differences inherent in the subject, partly on 
different exciting causes. What is called Sthenic inflammation is that 
which occurs in a healthy person, either spontaneously, or from ex- 
posure to cold, or the application of some irritant which does not con- 
taminate and depress the general system. The symptoms, if the in- 
flammation is extensive, run high, the febrile excitement is considerable, 
and free depletion is required and borne well. The exudations contain 
much plastic matter, and pus, if formed, is of the kind termed laudable. 
Asthenic inflammation occurs in persons originally weakly, or rendered 
so by the action of the exciting cause, as in the inflammations of influ- 
enza ; the pulse, though frequent, has no strength, the fever is of a 
lower type, and the effused matters manifest little plasticity. The 
terms acute, sub-acute, and chronic, have reference mainly to the pe- 
riods of duration of the inflammation, or to the rapidity or slowless of 
its course. Acute inflammation is often, but not necessarily, sthenic ; 
chronic and sub-acute are often not asthenic. Many changes are com- 
monly said to proceed from chronic inflammation which probably belong 
more to the class of degenerations : it is, however, difficult to draw any 
marked line between the two. The chief value of the terms lies in their 



126 INFLAMMATION. 

affording a kind of scale whereby to apportion the activity of treat- 
ment ; to the chronic affection we must oppose a remedy of slow and 
gradual action ; the acute must be met more " heroically." It is im- 
portant to be aware that an inflammation may be sub-acute or chronic 
from the outset ; an acute inflammation cannot well be overlooked — a 
chronic, if unpreceded by acute symptoms, may easily be : such inflam- 
mations are sometimes said to be latent. Congestive inflammation differs 
not much from asthenic ; its effusions are of the same kind, but it par- 
takes in a considerable degree of the nature of passive hyperemia — 
indeed, is such originally, and has, subsequently, inflammation, acute or 
sub-acute, grafted upon it. This must be remembered in treating it. 
The chief character of erythematic or erysipelatous inflammation is its 
tendency to spread and travel over an extensive surface : this seems to 
depend, at least in part, on the peculiar character of the effusion, which 
consists, for the most part, of serum, or sero-purulent matter, and not 
of fibrin, which in phlegmonous inflammation^ establishes a barrier 
between them and the surrounding textures. The general symptoms 
are in most cases those of adynamic or typhoid fever ; depletion is 
injurious, and stimulants required at an early period. There is good 
evidence to show that a peculiar poison, capable of being communicated 
by infection, is the cause of these inflammations, and that this acts 
upon and modifies the system, even before the phlogistic process has 
made its appearance. They are, therefore, with respect to their ex- 
citing cause, to be ranked together with other inflammations, such as 
the rheumatic, gouty, syphilitic, &c, which each manifest certain peculiar- 
ities, but depend, essentially, upon the presence of some materies morbi'm 
the blood. To the same class belong most of the inflammations which 
constitute skin diseases, which exhibit very remarkable instances of the 
effect of different states of the blood in determining the kind of inflam- 
mation that shall occur. To this we shall refer again, under the head 
of "Crasis." These inflammations also exhibit very clearly the affinity 
of certain parts of the tissues for certain morbid matters, which are 
their exciting causes ; thus, lepra has its seat of election about the 
prominence of the knees and elbows, eczema prefers the side of flexion 
of the limbs and the bends of joints, lichen affects the outer sides. 
The same is exemplified in the action of many medicines and poisons ; 
arsenic, in small doses, produces conjunctivitis — in larger, inflammation 
of the stomach and intestines, corrosive sublimate inflames the larger 
intestines, mercury, the gums, and so on : in all these cases the affinity 
or attraction of the elements of the tissue for the substance is clearly 
evinced. Diphtheritic inflammation is characterized by the early ex- 
udation upon mucous surfaces of a film or membrane of fibrinous matter 
of dirty white or grayish appearance ; this may extend over a consider- 
able tract, commencing often in the fauces, and thence spreading to - 
the mouth, the larynx, the air-passages, the oesophagus, and more or 
less of the alimentary canal. The subjacent mucous membrane is but 
little swollen, of a deep dull red, and inclined to bleed on the removal 
of the exudation. The attendant fever is of a low kind, and much of 
the danger depends upon the insidious, almost latent manner, in which 
the exudation takes place, so that suffocation may be actually threat- 



INFLAMMATION. 127 

ened before alarm is taken. This kind of inflammation occurs most 
often in epidemics, and is more frequent on the Continent than in Eng- 
land. It has been observed in France, that, during its prevalence, 
wounds and ulcerations assumed an unhealthy character, and were in- 
disposed to heal. Its cause is, evidently, a peculiar asthenic state of 
the system generally, involving a peculiar crasis of the blood, induced 
by atmospheric influences. Instances of a somewhat similar kind, but 
in which the asthenic character is much less marked, are occasionally 
met with among ourselves ; among these we should rank the so-called 
bronchial polypi, the pieces of membrane which are passed after the 
irritation of calomel, and in some other cases of intestinal disorder, and, 
probably some of the membranous exudations of dysmenorrhoea. The 
aphthae of children and adults belong more to the true diphtheritic 
exudations ; they contain, often, a large proportion of a confervoid 
growth, which has been regarded, indeed, as constituting their essential 
cause. This, however, in Rokitansky's opinion, is not the case. To 
this subject we shall refer again, under the head of "Parasites." 
Hemorrhagic inflammation is another variety ; it seems chiefly to 
occur in individuals predisposed to hemorrhage, or in places where 
scurvy is prevalent. Dr. Williams has found it associated with cirrho- 
sis of the liver, and granular degeneration of the kidney. His opinion 
is, no doubt, correct, that it is more dependent on an altered condition 
of the coloring matter, than on a deficiency of the fibrin. Its cha- 
racter is decidedly asthenic. Scrofulous inflammation is not so much 
a distinct variety as some others. It is commonly excited by the irri- 
tation of existing tuberculous deposit, which is occasionally mingled 
with its exudative products. These are distinguished in general by 
their aplastic character; they are deficient in coagulating fibrin, and 
are often thin and serous. The vital power of the system, both blood 
and tissues, is essentially defective ; and is the cause, at once, of the 
deposit which excites the inflammation, and of the low character of the 
process itself. 

We have already alluded to the causes of inflammation in the fore- 
going remarks, and shall now do little more than briefly enumerate 
them. Predisposing causes are almost always debilitating influences ; 
a strong part is less liable to inflame than a weak one — a previous attack 
of inflammation especially renders a part more prone to undergo a 
second. Certain unhealthy conditions of the blood (of which that in- 
duced by foul air is one) predispose the system to inflammation from 
trifling causes, which would pass inoperative in a sound state. Ex- 
citing causes are either such as act on the part directly which they 
inflame, or indirectly through the medium of another. The first may 
be mechanical irritants, such as a splinter in the flesh ; or chemical, as 
a strong acid, or acrid salt ; or vital, such as mustard, &c, whose opera- 
tion only affects living structures. It is remarkable that the urinary 
and biliary secretions which excite only healthy action in the mucous 
surface over which they naturally flow, and which, or at least some of 
their constituents, produce no particular injurious effects when absorbed 
into the blood, act as the most violent and fatal irritants upon serous 
membranes, and the areolar tissue, when infused into them. This shows 



128 INFLAMMATION. 

clearly the important part played by the tissues themselves in the pro- 
cess of inflammation : that which is a healthy stimulant to one texture 
is the cause of destructive inflammation to another. The production 
of local inflammations from the presence of some substance in the gen- 
eral mass of blood, for which certain parts seem to have a special affinity, 
has already been noticed, but we may add, that it is in these cases that 
we observe the interesting phenomena of symmetrical disease ;* the 
corresponding parts of the two lateral halves of the body being affected 
almost to the exclusion of others. Here, again, we have evidence of 
the predominant influence of the tissues, the parts which are exactly 
alike are affected alike, and the materies morbi passes by others. How 
unable is the neuro-pathological theory to explain such instances of 
inflammation ! 

The second class of causes are those which act indirectly on the. part 
which suffers. The most common of these is cold, which appears to act 
by repelling the blood from the surface, and causing it to accumulate in 
some internal part. This will be different, according to the previous 
predisposition; thus one person, as the result of a severe chill, will have 
bronchitis, another diarrhoea, a third peritonitis, a fourth renal conges- 
tion, and so on. Malaria, the repelling of eruptions, the arrest of habi- 
tual discharges, the sudden healing of ulcers, are also recognized as 
causes of internal inflammations, which they probably produce in the 
same way as cold, but the active congestion of the incipient process is 
more apt to issue in hemorrhage. It is matter of much uncertainty as 
to how many inflammations originate; they come on, as it seems, spon- 
taneously, without the individual being aware of any exciting cause. 
Both as respects these, and those which are produced by cold, &c, it 
seems to us necessary to recognize some special condition of the tissue, 
which in the one case converts the congestion into an inflammation, and 
in the other, is the sole and efficient cause. In ague, for instance, 
during the cold stage of each paroxysm, considerable congestion of the 
internal viscera takes place, but inflammation of these is comparatively 
rare. In healthy states of the system, the surface may remain severely 
chilled for several hours, during which the blood must accumulate in 
the internal organs, but this does not occasion inflammation. These in- 
stances show that mere repellent influences producing congestion are 
not adequate to produce inflammation solely by themselves. Even in 
the case of a common catarrh there is much reason to believe that the 
inflammation of the mucous surface depends much more on some pre- 
existing dyspepsia, or unhealthy condition of the blood, than on expo- 
sure to cold or wet ; and, in fact, many a cold occurs without any such 
exposure. In such cases, the predisposing cause becomes the most im- 
portant, or may even be the exciting also. We have not yet noticed the 
nervous influence in its relation to the causes of inflammation. This is 
considered the prime mover in the process by those who adopt the neuro- 
pathological theory : in our view it holds a very secondary place. That 
disturbance of the nervous force may prove a cause of inflammation, 

1 For a most interesting exposition of the subject of symmetrical diseases, we refer to 
Mr. Paget's Lectures for 1847. 



INFLAMMATION. 129 

cannot be doubted: Lallemand (quoted by Dr. Williams) " relates a 
case in which a ligature, involving the right brachial plexus, was followed 
by inflammation and suppuration of the opposite hemisphere of the 
brain. Mr. Paget mentions a case in which a portion of a calculus im- 
pacted in the urethra excited inflammation, with deposits of lymph and 
pus in the testicle. Instances of a similar kind, or of active hyperaemia 
similarly occasioned, are not very rare, and they certainly prove the 
capability of the nervous influence to set on foot the inflammatory pro- 
cess. But we have already given abundance of evidence that it is not 
through this channel that the causes of inflammation usually operate, 
and for a summary of the arguments we would refer to Dr. Williams's 
work, p. 249. Coinciding, as we completely do, with Mr. Paget, in his 
enumeration of four conditions as necessary to healthy nutrition, and 
believing that the derangement of one of these primarily, with secondary 
derangement of the others, occurs in every case of inflammation, we 
might divide the various causes which we have noticed into such as 
affect — (1) the contractility of the vessels ; (2) the healthy crasis of the 
blood ; (3) the nervous influence ; (4) the life and nutritive actions of 
the part. 

In strict language, there is only one termination to the inflammatory 
process, viz : that which is commonly called resolution, in which the 
diseased action ceases to advance, and then recedes by the same steps as 
those by which it arrived at the condition of stasis. The microscopic- 
ally visible phenomena have been before described, and they corre- 
spond to the subsidence of the general symptom, to the paling of the 
redness, the lowering of the temperature, the lessening of the swelling 
and pain. The recovery of the part may be complete ; but more often 
some, it may be slight, indications remain, for a time, of the by-past 
malady, and of some deficiency of the vital powers. These consist, in 
some degree, of congestion of the vessels, especially the veins, from an 
enfeebled state of their contractility, in a less perfect fulfilment of the 
function of the part, and in a proneness to relapse on the application of 
slight exciting causes. Inflammations which arise in consequence of a 
mal-crasis of the blood, rarely undergo resolution, or if they do, it is 
only to reappear in another part, and perhaps a more important. This 
constitutes metastasis. A good example of this transfer of inflammation 
from one part to another is afforded by some cases of rheumatism, and 
occasionally by the disease called mumps. As long as the materies 
morbi continues to circulate in the blood, it will tend to excite inflam- 
mation in one part or other ; the best thing that can happen is, that it 
should locate itself in a part where it can produce no serious effects from 
interference with important functions, and there remain until the dys- 
crasia is at an end. One important remark of Rokitansky's must not 
be omitted, viz : that even resolution does not, especially if the inflam- 
mation has been extensive, leave the system in as favorable a condition 
as before the attack, since a large quantity of liquor sanguinis, which, 
during the stasis, has undergone certain changes, is set free, to mingle 
with the general mass of the blood. This must produce a contaminating 
effect until it be eliminated. Hence the benefit of a free action of the 
skin, of a free flow of urine, purging, &c. 



130 



INFLAMMATION. 



But in order that resolution may take place, it is absolutely essential 
that no considerable amount of effusion should have occurred; if this is 
the case, the affected tissue remains clogged and otherwise injured by 
the presence of solidified matter in its interstices. This matter and the 
tissue may also undergo further changes. We thus come to the con- 
sideration of, firstly, inflammatory exudations; and, secondly, of the 
changes that take place in the tissues affected by them. The fluid effused 
in inflammation is commonly the liquor sanguinis, more or less modified, 
especially containing a less proportion of albumen and fibrin. An ana- 
lysis, by Simon, of fluid obtained by paracentesis thoracis, shows, in 
1000 parts, 934.72 of water, 1.02 of fibrin, 1.05 of fat, 48.86 of albumen 
and albuminate of soda, 11.99 of extractive matter, and 9.5 of fixed 
salts. The quantity of fibrin varies considerably. Some effusions con- 
sist chiefly of it, others contain very little; generally, it may be, said, 
its quantity is in proportion to the vigor of the system, and the acute- 
ness and sthenic character of the inflammation. The fibrin may coagu- 
late quickly, or remain in its fluid state, for a length of time, in the 
part where it is effused. Blood-corpuscles, or dissolved haematin, may 
be mingled with the exuded matter in various proportions. Though we 
often speak of serous effusions as the result of inflammations, yet the 
opinion expressed by Mr. Paget is probably correct, that " an effusion 
of serum alone is a rare effect of inflammation, and that generally it is 
characteristic of only the lowest degrees of the disease." He mentions 
as instances inflammatory oedema of the mucous folds above the glottis, 
chemosis of the conjunctiva, and some forms of hydrocephalus. The 
fluid obtained from blisters contains either distinct fibrinous coagula, or 
only a small proportion of fibrin, together with multitudes of puriform 
corpuscles. 

No doubt, in inflammations of different characters, there must exist 
great differences in the composition of the serous fluid effused, and in 
its particular qualities and tendencies. There must be great variations 

Fig. 14. 




Fibrinous exudation on pleura in process of absorption; areola? form in it, and reduce it to filamentous 

bands. 



in the proportion of oil, of extractive and saline matters in the effusions; 
but respecting these we have scarce any information. The chemical 
examination of inflammatory products is very difficult, partly in con- 



INFLAMMATION. 



131 



sequence of the impossibility of procuring more than very small quan- 
tities, partly because they can so seldom be obtained pure; and almost 
the whole of our knowledge, therefore, has reference to the differences 
which are perceptible to the eye and to the microscope in the solidified 
and shaped constituents of the exudation. These, however, afford very 
valuable indications for forming a judgment of the nature and tendency 
of the process from which they spring. We have already given Ro- 
kitanky's account of the varieties of fibrin, as seen in intra-vascalar 
coagula, and stated the important circumstance that they correspond 
closely with those observed in exudations ; but it still seems desirable to 
present an abbreviated sketch of the latter from the same authority, in 
order to furnish a kind of scale of varieties, to which observers may 
refer different specimens they meet with, and to elucidate, as much as 
possible, a process which meets us at every turn. 

Rokitansky describes two varieties of fibrinous exudation, the simple, 
or plastic, and the croupous. The first appears as a flaky-fibrous trans- 
parent blastema, of remarkably sticky quality, tear- 
ing, as a fibrous felted mass, with numerous nuclei Fig. 15. 
and nucleated cells scattered over it. It corresponds 
to the second variety of intra-vascular fibrin. Such 
an exudation constitutes the material by means of 
which wounds are united that heal by the first 
intention, and is often found forming the false 
membranes upon serous surfaces, or the induration- 
matter of parenchymata. It may undergo meta- 
morphosis ; (1) by being more or less entirely 
absorbed, in which Rokitansky considers the serous 
part of the exudation to act as a corrosive or dis- 
solving menstruum; (2) by becoming obsolete, t. e. 
drying up into a horn-like mass, which may after- 
wards ossify; (3) by undergoing a change (of de- 
velopment) into fibroid tissue. New vessels may 
from in it more or less abundantly, or it may obtain 
a smooth, polished surface, like that of a serous 
membrane, as is occasionally seen in the arachnoid. 
The croupous exudation is, in general, characterized by a high degree 
of coagulability, a yellow or greenish-yellow color, opacity, deficient 
capacity for becoming organized, speedy breaking up, and diffluence, 
very often by a corroding property, which brings the tissues, as it were, 
into a state of fusion. 

The croupous exudation-process and its product are further remarkable 
by (1) the usually excessive, exhausting quantity of the exudation, and 
its extension over large surfaces of tissue ; (2) by the acute occurrence 
of the exudation, since a pre-existing crasis is the fundamental cause of 
the stasis; (3) by the often very slight degree of injection of the diseased 
tissue, which may depend either on the blood-corpuscles being concealed 
by the opaque hyperinotic plasma, or on the large quantity of exudation, 
inducing quickly emptiness and collapse of the vessels; (4) by a less 
sticky quality; (5) by a considerable amount of fat. The principal 
alteration which this exudation undergoes is the above-mentioned diffiu- 




Copied from Gullivers 
Trans, of Gerber, may be 
taken as an explanatory 
diagram of commencing 
organization in effused 
fibrin. 



132 INFLAMMATION. 

ence, by which it breaks up into a fluid, more or less analogous to pus. 
This change especially affects the coagulated solid part. When thus 
fluidified it may be absorbed, or may leave behind a partial residuum, 
of a cheesy, fatty, pappy fluid, containing granular, cretaceous, and oily 
molecules, granule-cells, and crystals of cholesterin. Variety (a) of 
the croupous exudation corresponds to variety (3) of the intra- vascular 
fibrin, like it consisting of varying proportions of felted fibres, punctiform 
and oily matter, and various granular nuclei and cells. Variety (j3) 
corresponds to (4) of intra-vascular fibrin. It consists of a shapeless 
basis-substance, containing a preponderance of punctiform matter, to- 
gether with nuclei and cell-formations, approaching more and more the 
character of those of pus. It is non-adherent to the surface, and quickly 
becomes diffluent. To these two varieties belong the various exudations 
of croup, those in many cases of meningitis, of pericarditis, and phlebitis. 
Most cases of pneumonia give rise to exudations of this kind, especially 
those in which a very abundant yellow, quickly-diffluent material is 
deposited, which causes great increase in the size of the lungs. 1 The 
corrosive quality of the diffluent exudations manifests a decided tendency 
to the early production of abscess and ulceration ; it is probably in the 
case of such exudations as these that the comparatively rare occurrence 
of pulmonary abscess takes place. Variety (y) of the croupous exudation, 
Rokitansky distinguishes as the aphthous, or, we may say, the diphthe- 
ritic. It forms a yellow or greenish-yellow mass, dirty-gray, and opaque, 
coagulating on surfaces into tenacious membranes, and thereupon break- 
ing up, and occasioning corrosive fusion of the tissues. The affected 
tissue may be simply corroded, or fused into an ill-looking, stinking, 
sanious pulp, or into a tenacious, tinder-like, dirty scab. Instances of 
this exudation are seen especially on mucous surfaces, as in muguet, 
diphtheritis, some forms of dysentery, of puerperal metritis, in the 
ulcerations of typhus, and those of hospital gangrene. These exudations 
are, for the most part, dependent upon a special crasis of the blood, 
which we shall afterwards notice. Rokitansky makes a third variety of 
fibrinous exudations, viz : the tuberculous, but we shall not notice it in 
this place, as we doubt the propriety of classing it in any way together 
with the foregoing. There is, however, one form which fibrinous ex- 
udation not unfrequently assumes, which resembles tubercle a good deal, 
and might be confounded with it. In this it constitutes small, firm 
nodules, which consist of a fibroid tissue, and do not undergo any of 
those changes which tubercle commonly does. They lie sometimes in 
great numbers in the sub-pleural, areolar tissue, and are often surrounded 
with black pigment. Rokitansky also describes albuminous exudations, 
as distinct from the fibrinous, but the separation scarcely seems to us to 
be warranted. They appear identical with the lower varieties of the 
croupous form, but modified, in some degree, by occurring in depressed 
conditions of the system; as where the blood is abnormally venous, from 
disease of the heart, or impoverished by effusions that have robbed it of 
much of its fibrin, or insufficiently renewed, in consequence of marasmus, 

1 Dr. Hodgkin believes, and we think he is right, that this condition of gray or purulent 
infiltration is not preceded by a stage of red hepatization. 



INFLAMMATION. 133 

old age, &c. The stasis, which gives rise to these exudations, is said 
to have very often an asthenic, hypostatic character, and protracted 
course. We have above noticed the rather rare occurrence of serous 
exudations which contain no fibrin. Rokitansky denominates these 
albumino-serous, or, if they contain fibrin, fibrino-serous, reserving the 
term " serous" especially for those which contain little or no animal 
matter. Of these, he says that they are thinly fluid, watery, clear, 
colorless, or pale yellowish, or even yellowish-red, and of saline taste. 1 
They may result from inflammation, but afford no proof by their presence 
of its having existed. They are, of course, capable of no organization, 
but seem to exert a deteriorating influence on the tissues where they are 
effused, "loosening and puffing them up, paralyzing their contractility, 
and manifesting, after long contact, a surprising enfeebling influence, 
especially upon muscular fibres." 

We proceed next to the examination of certain processes, which are 
of extremely frequent occurrence in inflammatory exudations, or which 
impress a peculiar character on them, even in their nascent state. These 
are the suppurative, and that which gives rise to the granule cell and 
other forms of celloid corpuscles. We will first describe the products, 
and afterwards consider the mode of their production and their import. 
There are many varieties of pus ; but that which is commonly called 
healthy (laudable) is that which we shall take for a typical description. 
It appears to the naked eye as a creamy, thick, opaque, and homogene- 
ous fluid ; communicates an unctuous feeling when rubbed between the 
fingers ; is of a yellow or whity-yellow tint ; sweetish, or insipid ; and, 
w T hile warm, gives off a peculiar, mawkish smell. Its specific gravity is 
1030 — 1033. If allowed to stand some time in a tall, narrow glass, the 
fluid separates into a thickish sediment, more or less abundant, and a 
supernatant serum. This serum, according to Vogel (whose account we 
shall use freely) is identical with the serum of the blood, containing 
much albumen, extractive and saline matters, and fat. The reaction is 
alkaline ; but it readily becomes acid, from the generation of an acid, 
which is commonly supposed to be the lactic. In some cases, however, 
according to Dr. Walshe, it has an acid reaction, even at the time of its 
formation. A peculiar substance, called pyin, by Guterboch, which 
Simon considers almost identical with mucin, is said by Rokitansky not 
to be one of the constituents of normal pus, but to proceed from croupous 
fibrin, in a state of diffluence mingled with it. The sediment consists 
almost entirely of small organized corpuscles, the well-known pus-glo- 
bules. These are of spherical form, have a well-defined contour, formed 
by a distinct homogeneous envelop, inclosing a mass of soft granulous 
substance, and a varying number of nuclear corpuscles. These are, in 
well-formed pus-globules, for the most part concealed by the surrounding 
substance ; but in the younger cells, even of healthy pus, and in all 
those of pus of an inferior kind, they are easily perceptible, even without 
the aid of acetic acid. Occasionally, a single nucleus exists ; but more 
commonly it is made up of two, three, four, or even five large granules. 

1 One of the best instances of the pure serous exudation (serosity, as some call it), is 
the fluid which distends the ventricles of the brain in acute hydrocephalus — 100 parts 
have been found to contain 1 of salt, A of animal matter, and 98.6 of water. 



134 



INFLAMMATION. 



The single nuclei are always the largest, and indicate, as we conceive, 
the most perfect kind of development. The more numerous the nuclear 
corpuscles are, the smaller do they become, so that the opinion seems 
very probable, that the perfect nucleus is formed by a coalescence of the 
smaller corpuscles; and that the bipartite, tripartite condition, &c, is 

Fig. 16. 




® @ ^ @ © • m & ® 



Corpuscles from a pustule. 

(a). Large granulous exudation globules. 

(6). Pus-corpuscles. 

(c). Nucleated fibres. 

(d). Pus-corpuscles, their nuclei brought into view by acetic acid. 

(a'). Granular exudation globules, their nuclei brought into view by the action of water. 



an indication of imperfect development. The nucleus is seated on the 
envelop, or is parietal, as it is termed. Its diameter is about q-Jq-q in.; 
that of the entire pus-globule about -g o*o o ^ n - Single (complete) as well 
composite nuclei, are seen floating in the serum of pus ; but they are 
not very numerous. We have also observed, as well as M. Lebert, small 
homogeneous, or faintly granular globules, about g 0*00 * n diameter. 
The observer just mentioned describes some globules which often occur, 
mingled with those of pus, but which differ from them in several par- 
ticulars, being smaller, more transparent, and non-nucleated. These 
he terms "pyoid." There is generally a small quantity of diffused 
granular matter mingled with the pus-globules. This is more abundant, 
according to our observation, in pus of low and ill development. It is 
not to be confounded with the so-called elementary granules, which 
Rokitansky describes as originally discrete, and, subsequently grouping 
together, to constitute the nuclei. Dr. Walshe says, that the chemical 
composition of these granules is not always identical; that they are 
sometimes soluble in ether, and sometimes exhibit the reactions of a 
protein compound. The formation of the pus-globule does not appear 
to take place in one uniform manner. The nucleus is generally stated 
to be first formed by the grouping together of granules, which appear 
in a fluid blastema. Around this there may be first formed the envelop, 



INFLAMMATION. 135 

closely embracing the composite mass, so as only to be brought into view 
by the endosmotic action of water, or, as we think is more frequent, a 
granulous deposit forms round the nucleus, and afterwards becomes 
limited and inclosed by a cell wall. Lebert describes the pus-globules 
as being formed in a different manner, which Rokitansky also seems to 
admit, and which we think actually, though not constantly, occurs. 
According to this view, minute granular globules, forming in a fluid 
blastema, grow and enlarge, granules appear in their interior, and gradu- 
ally assume the appearance of the composite nuclei. The globule is, in 
fact, from the first, a miniature of the fully developed one. It is formed, 
in the French phrase, " de toutes pieces." The recognition of this diver- 
sity in a formative process, is surely an important step. It is stated by 
Vogel that pus may be formed from a solid blastema of coagulated fibrin. 
" The pus-globules," he says, "are at first scantily dispersed through 
the stroma. Afterwards they become more abundant, and ultimately 
occupy the whole space, while the solid fibrin disappears." In this 
way, he states, pus is formed in all cases, where suppuration is conse- 
quent upon induration, as in the lung after hepatization, in solid exuda- 
tions upon serous surfaces, and so on. In Rokitansky's opinion, these 
instances of suppuration really depend on the original combination of 
elements of pus with croupous fibrin. The latter breaks up, and becomes 
a diffluent mass ; but yields nothing in the way of nutriment to the pus 
elements, which increase and develop themselves solely out of the sero- 
albuminous fluid, mingled with the fibrin. The changes taking place in 
intra-vascular coagula, which we have before described, bear upon this 
question, in connection with which we would also refer to some excellent 
remarks, by Dr. "Walshe, in his article on Advent. Products. (Cyclop. 
Anat. and Phys.) To us it appears that it must be conceded, that ele- 
ments may form in softening fibrin, indistinguishable from those of pus : 
and, indeed, Rokitansky's own description of croupous fibrin proves that 
such are present from the outset, so that we are inclined to adopt Vogel' s 
opinion, that solid effusions may undergo actual conversion into pus, 
just as we know they may into fibroid tissue. The pus-globule is not 
very remarkably affected by being placed in water. It becomes some- 
what swollen and more spherical, but is not destroyed and burst so 
rapidly as the blood-globule — the nucleus becomes somewhat more appa- 
rent. In blood, urine, mucus, saliva, it is unaltered. Acetic acid renders 
the granulous contents translucent, and brings out the nucleus more 
definitely. It renders the envelop also more transparent, but does not 
destroy it. Other dilute acids have a similar effect. Caustic and car- 
bonated alkalies, and borax, convert the whole corpuscle into a viscid 
mass, leaving only very minute dark molecules, whose import is uncer- 
tain. Pus, Dr. Walshe says, possesses a remarkable power of resisting 
decomposition. At the end of months some corpuscles may still be found 
unchanged, among others that are dissolved. It even retards the putre- 
faction of substances which are placed in it ; but at the same time seems 
to exert upon them a corrosive influence. Pieces of flesh, put into fresh 
pus, gradually lost weight, and were at last dissolved, without any evi- 
dence of putrefaction having occurred. Mr. H. Lee has recently shown, 
that pus possesses a remarkable power of accelerating the coagulation 



136 



INFLAMMATION. 



of blood. In one experiment the blood, which had pus (healthy) added 
to it, coagulated in six minutes; while that which was left by itself re- 



Fig. 17. 







<g)§> Qa) 






Fig. 19. 



mk»M 






Fig. 21. 





Fig. 18. 




Fig. 20. 





Fig. 23. 




Fig. 18. a. Natural appearance of pus-corpuscles, b. Appearance after application of acetic acid. 

Fig. 19. Pus-corpuscles, magnified 400 diameters. 

Fig. 20. Healthy pus-cells. 

Figs. 21, 22, 23, Various forms of pus-cell from phlebitis and pyaemia. 

quired twelve. The pus must, of course, act upon the fibrin; but of the 
nature of the change, we have no knowledge. The following analysis, 
by Dr. Wright, exhibits the main features of the chemical constitution 
of pus very well. They apply, of course, to pus as a whole, not to the 
serum only. The large quantity of fat in pus is remarkable, as well as 
the amount of albumen — the latter sometimes exceeding that contained 
in the liquor sanguinis. This is probably to be explained by the disso- 
lution of some of the red globules, and the blending of their albuminous 
globulin with the exudation that yields the pus. 



INFLAMMATION. 137 





From a vomica. 


From Psoas abscess. 


From Mammary abscess. 


Water 




894.4 


885.2 


879.4 


Fatty matter 
Cholesterin 


• 


17.5 \ 
5.4} 


28.8 


26.5 


Mucus 




11.2 


6.1 




Albumen . 




68.5 


63.7 


83.6 


Lactates, carbonates 


sul-" 


1 






phates, and phosphates 


► 9.7 


13.5 


8.9 


of soda, potash and lime , 


1 






Iron . 




a trace 






Loss . 


. 


3.3 


2.7 


1.6 




In various unhealthy states of the system pus is formed, which differs 
in several respects from that which we have now de- 
scribed. Mucin, the peculiar principle of mucus, may Fl S- 24. 
be more or less abundantly dissolved in the serum, 
which may be recognized by the coagulation produced 
by acetic acid and alum. Small fibrinous flakes, epi- 
thelial particles, cholesterin scales, and prisms of 
triple phosphate may also be mingled with it, as well 
as varying quantities of free oil. The pus-globules 
are in such cases often ill-shaped, feebly formed, con- 
veying the idea of very defective formative power ; the quantity of 
granular matter mingled with them is much increased. 

One variety of pus has been called ichor, and is especially distin- 
guished by the paucity of its corpuscles, which, indeed, Vogel says, are 
absent when it is perfectly pure. Its color is reddish, or brownish red, 
it is alkaline, and contains a considerable quantity of albumen. Its 
presence indicates an exceedingly depressed state of the vital formative 
power. Certain unhealthy kinds of pus, which Rokitansky comprises 
under the term (Jauche) sanies, are especially distinguished by their 
corrosive action upon the tissues, which he contrasts particularly with 
the bland quality of healthy pus. Their appearance is not at all con- 
stantly different from that of the normal fluid, but they are apt to be 
thinner, more tinged by hsematin, of an offensive, or ammoniacal smell, 
and to communicate a sensation of pricking or itching to the finger 
when applied to them. Their corpuscles are stunted, and their develop- 
ments are variously altered, apparently by the " gnaiving" action of 
the serum in which they float. It seems to us very questionable, 
whether the dissolving action which pus is said to exert on pieces of 
dead flesh, belongs at all to it in a healthy and fresh state, and whether 
it does not really depend on the generation of acids within itself, in 
consequence of decomposition. Purulent effusions may degenerate into 
a semi-fluid amorphous mass, the corpuscles breaking up, and the serum 
undergoing chemical changes, often of a putrefactive kind. They may 
also undergo fatty degeneration, calcareous salts being liberated, or 
deposited at the same time. Either of these two changes being pre- 
mised, it is possible that a purulent collection may be absorbed, but it 
is only too probable that in the former case the result will be a fatal 
contamination of the blood by the decomposing matters taken up into 
it. Apparent temporary absorption may be easily produced by means 
which, creating a considerable demand for fluid, withdraw the serum 



138 INFLAMMATION. 

from the pus-corpuscles ; but as these retain their vitality, they soon 
attract a fresh quantity of blastema from the blood, and the abscess 
remains undiminished. This persistent vitality of the organized cor- 
puscles of a fluid which is regarded as effete in the highest degree, and 
incapable of any further development, is certainly remarkable ; one 
would rather have expected that they would have disintegrated rapidly. 
Pus may be confounded with some other fluid, and the distinction is 
sometimes only to be made out by careful microscopical examination. 
What we have said respecting softened fibrin, will show that a fluid 
having this origin may approach very closely to the purulent product 
of inflammation ; so much so, that it may be doubted whether it be not 
in part identical with it. It has happened several times, that a quantity 
of desquamated epithelium, the particles being partly entire, partly 
broken up, has been mistaken for a collection of pus. Vogel records 
an instance of this in the pelvis of the kidney of a person who died with 
empyema. The pus-like fluid accumulated in the urinary passages, 
was deemed convincing proof that absorption of the thoracic effusion 
had been taking place with subsequent elimination of the same by the 
kidneys. The microscope, however, showed that the whitish-yellow, 
thick, creamy fluid which had been considered as pus by all who saw it, 
consisted entirely of epithelial debris. We shall presently describe 
mucus, and will then point out wherein we believe it to differ from pus. 
A caution is necessary against a very possible error which even prac- 
tised observers have committed, viz : that of mistaking the colorless 
corpuscles of the blood for pus-globules. The two bodies are very 
much alike, but the blood-corpuscle is somewhat smaller, generally more 
finely granular, and with rather less definite contour. The interior 
nuclei of both are identical. 

The granule-cell, exudation globule, or glomerulus, which was first 
described by Gluge, and called by him the compound inflammatory 



Fig. 25. 



® Jt> 





&^l!# ¥ 



* a '», 



Glomeruli and granulous cells. 

(1) From ovarian cyst. 

(2) From cancer of breast. 

(3) From inflamed lung. 

(4) From inflamed pia mater. 

(5) From a case of tuberculous meningitis. 

The opaque cells are the glomeruli, the more simply granulous are the granular cells. 

globule, is very frequently present in exudation, and is, speaking gene- 
rally, a valuable sign of the existence of the inflammatory process, but 



INFLAMMATION. 139 

not an infallible one. The granule-cell is usually of large size, from 
34 oo — ?go i ncn > mostly spherical, but often oblong, or of irregular 
shape. By transmitted light they appear dark, on account of their 
opacity ; by direct, of a dead white. Their structure will be best un- 
derstood from the account of their development. Our own observation 
exactly accords with that of Vogel, who states that there are first formed 
in the blastema nucleated granular cells, which gradually fill themselves 
with the peculiar opaque glistening granules characteristic of these 
corpuscles, until at last the nucleus is entirely obscured, and the origi- 
nally smooth-cell membrane becomes rugged, the granular cell appear- 
ing as an agglomeration of granules. Subsequently the cell-wall van- 
ishes, the granules separate from each other, probably on account of 
the dissolution of the uniting substance, and the corpuscle breaks up 
into a loose heap of oily-looking granules. Vogel says that caustic 
potash and ether sometimes, but not always, dissolve these granules ; 
Rokitansky regards them as of fatty nature, and considers the process 
of granule- cell formation as one of fatty degeneration of pre-existing 
cells. He says that granule-cells do not form in blastemata devoid of 
cells, and that any cell may undergo this transformation, a cancer-cell, 
a pus-cell, as well as the cells that form in exudations. There is no 
doubt that blastemal exudations, devoid of cells, often break up into 
collections of the fatty-looking granules, and that they may assume 
this form from a very early period; as, for instance, in the coating of 
the vessels in the gray matter in meningitis. Corpuscles also, quite 
indistinguishable from granule-cells, occur in lungs that bear no trace 
of having ever been inflamed, and this in considerable numbers. We 
do not think, therefore, that Bokitansky's view of the nature of the 
process is quite correct, but are inclined to believe that, generally, where 
blastemal exudation has been poured out in greater quantity than is 
necessary for the nutrition of the tissue, it may undergo such a change, 
as that its oil, in combination with a part of its albumen, separates in 
the form of glistening granules, while the remainder undergoes absorp- 
tion, or is otherwise consumed. The granules appear to be attracted 
towards the interior of existing cells ; we have distinctly seen them 
coating the outside of a cell. One of the causes of the different size 
of the granule-cell depends on the circumstance that cells of very 
different magnitude, and cells in very different stages of growth, may 
be the seat of their deposition. Between the suppurating process and 
that which forms granule-cells, a wide separation exists ; the former, as 
we have seen, gives rise to a fluid essentially effete, rarely, with diffi- 
culty, or with peril, capable of being absorbed ; the latter involves no 
such deteriorating alteration of the blastema ; its occurrence, on the 
contrary, is eminently favorable to reabsorption of an exuded mass. 
It is to be remarked, in conclusion, that a very abundant cell-growth 
commonly takes place in exudations, many particles of which are cor- 
rectly denominated granular cells. These are not to be mistaken in 
descriptions for the granule- cells, into which they often undergo meta- 
morphosis. The similarity of the name is unfortunate, but the sub- 
joined sketch will make the distinction between the two very apparent. 
The last inflammatory product which we have to notice is mucus. 



140 INFLAMMATION. 

Speaking correctly, it is only unhealthy mucus which comes under this 
head ; for it is perfectly clear that several internal membranes secrete a 
mucous fluid. The distinction between this and the morbid product is 
tolerably precise, and easy to be ascertained. The former is a tenacious, 
clear fluid, containing only some admixture of the epithelium of the 
membrane producing it, and having no special corpuscles of its own. 
The latter is loaded with corpuscles, identical with those of pus, together 
with a varying quantity of epithelial debris. Between such mucus and 
pus it is evident that a close analogy subsists. Mucus may be dis- 
tinguished, like pus, into a fluid, the liquor muci, and corpuscles. The 
liquor muci, as we find it in the secretion of a membrane which has been 
subjected to moderate irritation, is a transparent, tenacious, more or 
less stringy fluid, of alkaline reaction, and more or less saline taste. 
The addition of acetic acid, or any weak acid, produces a kind of coagu- 
lation, and the formation of a granular precipitate, which Simon states 
is the mucine, the principal constituent of the fluid. This is held in 
solution by means of an alkali, and consequently falls on the latter 
being taken up by an acid. Not much is known of this substance, ex- 
cept that it is a protein compound. Albumen or fibrin, treated with 
liquor potassaB, forms a transparent, viscous mass, having much resem- 
blance to its solution. The proper corpuscles of morbid mucus are, as 
we are fully persuaded, and as the best observers state, quite identical 
with those of pus. They are usually mingled with epithelial particles, 
in very various stages of their formation, from a simple nucleus up to 
a complete cell. It is only in cases of prolonged and rather intense 
inflammation that traces of epithelium are wanting, and the so-called 
mucous corpuscles are crowded together, and seem to load the fluid. 
In mucus expectorated by persons of very depressed powers, the cor- 

Fis;. 26. 



o 



Separate corpuscles, and two Mood-globul 



puscles may be seen feebly formed, like those of pus secreted under 
similar circumstances; the granular contents of the cell are deficient, 
and allow the composite nuclei to be distinctly seen. It is often very 
observable how the tenacious fluid, in which the corpuscles are entangled, 
in consequence of being dragged in one direction, produces an alteration 
of their shape; they thus become oval, or even staff-shaped. Granulous 
and oily matter is commonly diffused through the liquor muci, just as 
it is through that of pus. It is manifest, from what has been stated, 
that the difference between mucus and pus consists essentially in the 
different nature of the fluids, not in that of their corpuscles. Both are 
exudations; but the one is poured out directly from the bloodvessels, as 




INFLAMMATION. 141 

an albumino-fibrinous blastema, in which special corpuscles (the pus-cells) 
are formed; the other transudes, not only through the capillary walls, 
but through the basement-membrane of the mucous surface, with more 
or less of attached epithelium, and in so doing experiences a peculiar 
modification, which remains impressed upon it, while the corpuscles 
mingled with it are either the natural cell-growth of the surface, or such 
as form naturally in blastemata, that are destined to become effete. 
Mucus, it is evident, is effete, Kke pus. It is hardly possible that any 
part of it should be absorbed again. A constant flow of it becomes, 
therefore, a serious drain upon the system, entailing a loss of so much 
protein matter. The old question, as to the means of distinguishing 
between pus and mucus, is manifestly of little moment, and has, in 
general, no interest for the practical physician. It is sufficient to state 
that the liquor puris is albuminous, the liquor muci not so; that pus will 
mix with water, and mucus will not; that pus is dissolved, in some mea- 
sure, by acetic acid, while mucus is coagulated; and that mucus generally 
contains traces of epithelium, while pus does not. It may, however, be 
observed, that if a fluid, secreted under inflammatory irritation, should 
lose the characteristic tenacity of the liquor muci, and come to contain 
albumen, there would be considerable reason to fear that the texture of 
the mucous membrane had become ulcerated, and that the albuminous 
exudation, no longer modified to mucus, was being poured out from 
exposed vessels. Any admixture of blood with the secretion would 
render this still more probable. 

Having considered the effusions of inflammation, we come next to exa- 
mine the various changes that may take place in a part inflamed. We 
enumerate these as : (1) Enlargement ; (2) Atrophy ; (3) Ulceration ; 
(4) Gangrene. The term " enlargement" is preferable to that of " hy- 
pertrophy," which is sometimes employed, because it conveys no such 
erroneous idea as that the part is truly increased in size by addition of 
more of its own proper substance, an occurrence which most rarely, if 
ever, is the result of any form of inflammation. The enlargement de- 
pends entirely on the infiltration of the tissue with some form of exuda- 
tion matter, which subsequently undergoes metamorphoses such as we 
have described, and is more or less completely absorbed. It often hap- 
pens, however, that a part remains behind, and is converted into a low 
form of fibroid tissue, or a semi-solid blastema, imbedding multitudes of 
nuclear particles. This constitutes induration-matter, which resembles 
very much that which forms cicatrices; like which, its tendency is to 
contract and shrink, thus compressing and obliterating the vessels of 
the part, and in this way, as well as by its pressure, inducing the atrophy 
of the tissues among which it is deposited. A good instance of primary 
enlargement and subsequent atrophy, resulting from inflammation, is 
afforded by some cases of cirrhosis of the liver. Rokitansky describes 
atrophy, the result of inflammation, as depending upon the mechanical 
injury done to the tissues, in the seat of inflammation, by the exudation, 
as well as upon their being deprived by it of their proper amount of 
nutrition. Being thus rendered unfit for the discharge of their func- 
tion, they fall to pieces, and are absorbed, together with the exudation. 
u This occurs with especial frequency in delicate, lacerable tissues, when 



142 INFLAMMATION. 

large quantities of exudation have been effused, and such as are solid 
and capable only of slow reabsorption. Thus, in the inflammatory foci, 
the substance of the brain, of the muscles, of the kidneys, &c. becomes 
lost, while there remains in its place one or more gaps, limited by cica- 
trix- tissue, which, if such gaps are small and numerous, causes a spongy, 
rarefied condition of the tissue." 

Ulceration implies that condition of a part in which more or less of 
its proper substance has become eroded, and has disappeared, in con- 
sequence of unhealthy action, so that a cavity remains. This condition 
does not most commonly exist alone, but together with a greater or less 
amount of exudative and organizing processes. These are so far from 
being essential to it, that they constitute, in fact, the means by which 
its ravages are repaired ; the formation of granulations, and the effusions 
of pus, are the characters, not of an extending, but of a healing ulcer. 
Instances of pure and simple ulceration are to be seen in the cornea, 
and in some ulcers of the walls of the stomach; they penetrate the tissue 
more or less deeply, so as sometimes to perforate it, without any sur- 
rounding thickening from the deposition of lymph. When the erosion 
of the tissue goes on rapidly and extensively, forming a sore, with very 
irregular surfaces and margins, and presenting no trace of reparative 
action, the ulceration is said to be phagedenic. Many other varieties 
of ulcers are mentioned, but they all have reference to the amount and 
character of the exudative and reparative processes taking place; and 
though they afford excellent indications of the condition of the general 
system, which are well worth studying, they are not to be regarded as 
containing anything special in the nature of the ulceration itself. Ro- 
kitansky considers that the main circumstance determining ulceration, 
is the corrosive quality of the exudation, the ichor. We agree with 
Mr. Paget in doubting the correctness of this as a general statement; 
it is much more probable that, in consequence of altered and defective 
nutrition, the tissue gradually deliquesces (so to speak) into a fluid, 
returning thus, though spoiled and effete, to the form of the healthy 
blastema, from which it originated. It is matter of some dispute 
whether the tissue, as it decays and is destroyed, is removed by absorp- 
tion, or is cast off from the broken surface. Mr. Paget inclines to the 
opinion that it is ejected, resting upon the analogy of excreting sur- 
faces, on the discovery of fragments of bone and phosphate of lime in 
ulcers of osseous structures, and on direct observation of the commence- 
ment of ulcers. We are also inclined to think that the process of re- 
moval is rather by ejection than by absorption, especially in the case 
of open ulcers, yet so that some amount of absorption also takes place, 
varying in degree in different cases, and probably even predominating 
in those where there is no external outlet. The formation of ulcerations 
on the surface of the cervix uteri, has appeared to us to take place in 
the following way, much as it is described by Dr. Baly on the intestinal 
surface: As the first step, in the situation of a spot of hypergemia, a 
minute vesicle is formed, the epithelial layer being lifted up by effused 
fluid, while the tissue beneath is softened, loosened up, and appears less 
dense than natural. Afterwards the covering of the vesicle is detached, 
the fluid escapes, and the tissue beneath appears still more lax and 



INFLAMMATION. 143 

spongy, and has evidently undergone loss of substance. The hyper- 
emia, persists. In this case, we feel little doubt that the deliquescing 
tissue is partly thrown off in the fluid which escapes from the vesicle, 
partly absorbed by the bloodvessels. 

It seems desirable to indicate the difference which exists between 
ulceration and absorption. In both, there may be considerable loss of 
substance at some one or more points of the part affected, but in ulcera- 
tion there is always an unhealthy state of the nutrition of the tissue, there 
is disease of it; in absorption, this is not the case: the part may be dimi- 
nished, but cannot be said to be diseased. Contrast a bone, carious 
and ulcerated from inflammation, with one which has undergone absorp- 
tion, in consequence of the pressure of an aneurism. 

The last result of inflammation which we have to mention is Gan- 
grene, or Mortification. This, indeed, is not a very common termina- 
tion, nor is it at all peculiar to the inflammatory process. It more 
really belongs to a deficient condition of vital power induced by various 
causes, which may of itself be the cause of the death of some part, or 
render it so feeble that it perishes under injurious influences which 
would otherwise have had no such effect. Gangrene may ensue from 
the following causes: (1) from an absolute and prolonged stagnation of 
the blood; (2) from a defective supply of blood; (3) from a general taint 
or unhealthy crasis of the mass of the blood; (4) from a local injury. 
The absolute stagnation of the blood in the first case may be the result 
of violent inflammation, especially of an asthenic kind, and occurring in 
debilitated systems and organs ; or it may be brought about mechani- 
cally, as when a portion of intestine is strangulated. Rokitansky says, 
that in this case the blood stagnant in the vessels first undergoes gan- 
grenous decomposition, and that, exuding through their walls in the 
state of gangrenous ichor, it sets up the same decomposing change in 
the surrounding tissues, which break up into a dark-colored pulp, of 
as little consistence as tinder; diffluent, and excessively stinking. In 
the second case, besides various kinds of obstruction of the arteries 
from external pressure, their channels may be blocked up by extensive 
fibrinous coagula, either forming spontaneously, or in consequence of 
disease of the coats of the vessels. Gangrene occurring in aged per- 
sons, without any apparent cause, that from the use of diseased grain, 
and hospital gangrene, are instances in which the morbid action is de- 
pendent on a general taint of the blood, or decay of the whole system. 
Mr. Simon suggests that the mode in which ergot of rye produces its 
fatal effect, may be by causing such contraction of the bloodvessels as 
prevents the flow of blood into the more distant parts, which conse- 
quently fall into the condition of dry gangrene. Spontaneous gangrene 
in old persons, or others, in which after death no obstruction of the 
bloodvessels is found, can only depend on an actual and premature loss 
of vitality in the part affected, the tissues of which are no longer able 
to carry on the actions of vital chemistry, and yield to those of inorganic, 
i. e. decompose, before the death of the system has actually occurred. 
In gangrene, from local violence, or from frost-bite, &c, the vitality of 
the tissues of the part is destroyed by the injury done to them. The 
general characteristic of gangrene in all these -cases is the failure of 



144 PYEMIA. 

vital action ; decay and death in the tissues, intense inflammation, 
absence of blood-supply, a poison circulating in its current, senile de- 
crepitude, a fearful laceration, may all have the effect of dissolving the 
vital affinities which hold together the elements composing the complex 
substances of our organism, and allowing them to fall back, as they 
naturally do, into the simpler compounds of inorganic chemistry. The 
distinctions of dry and moist gangrene, of black and white, of inflamma- 
tory and cold, have reference very much to the state of the affected 
part, with regard to the supply of blood. If the gangrene have its ori- 
gin in inflammation, there will be a considerable quantity of fluid ichor 
effused, and the color of the part will be of a deep red, or almost black. 
On the contrary, if the gangrene depend on deprivation of the supply of 
blood, the part will be more dry, and of a pale color. Sometimes, 
especially from the effect of ergot of rye, a limb dries and shrinks up, 
becomes mummified, as it is said, with little change in color. A black 
color is, however, often observed in parts affected by gangrsena senilis; 
this, no doubt, depends on alteration of the blood in the vessels, though 
there is often no hyperemia. Soft tissues are more liable to mortify 
than such as are of a firmer consistence ; bones, elastic and fibrous tis- 
sues, resist longer than muscles and mucous membranes; the large 
vessels and nerves are sometimes seen completely exposed by the 
ravages of hospital gangrene, all the tissues being removed from around 
them. 

The constitutional disturbance which often supervenes on gangrene is 
easily to be accounted for by the absorption of decomposing matters into 
the blood, which act as a virus upon it, and render it unfit to maintain 
healthy action. 



PYEMIA. 

Proceeding to consider various diseased states of the blood, we come 
next to one, in which a product of inflammation, viz : pus, is believed in 
some way to be mingled with the blood, and, by poisoning it, to produce 
both general fatal depression of the powers of life and local purulent accu- 
mulations, the so-called secondary depots, in various important organs. 
The phenomena observed in pyaemia are somewhat as follows: A man has 
received an injury, or undergone some surgical operation, it may be an 
amputation, or that for fistula in ano ; for a time all proceeds well, but 
soon shiverings come on, with adynamic fever and oppression, he ema- 
ciates, pain or disorder shows itself in some internal viscus, and in a 
few days he dies in a state of stupor, or delirium. On opening the 
body, the blood is found less coagulated than is natural ; there are ab- 
scesses more or less numerous commonly in the liver and lungs, and 
often in other parts ; there is frequently purulent effusion in the cavities 
of the joints, and sanguineous or purulent effusion in the serous cavities 
also. The question to determine is, how these morbid changes are 
brought about. From the almost invariable occurrence of such pheno- 
mena in persons who were the subject of suppuration, or in whom it was 
reasonable to believe, that pus might be formed in the seat of some 



PYEMIA. 145 

injury, it was natural to conclude that the pus, making its way into the 
blood, was the cause of the mischief. This was confirmed by Cruveilhier's 
experiments of injecting mercury into a vein, after which there was 
found in the centre of each of the small abscesses a globule of the metal 
which thus seemed to have been carried in the circulation to the part 
where it was deposited, and where it excited inflammation passing into 
suppuration about itself. The pus-globule was supposed to act in the 
same way as the globule of mercury; being too large to traverse the 
capillary channels it was arrested there; and similar obstructions taking 
place in other points of the same organ, a number of separate inflamma- 
tions, which soon suppurated, and formed the so-called multiple abscesses, 
were thus established. Another confirmatory fact of the same view was 
observed in these experiments, viz : that the mercury was arrested 
almost entirely in the first set of capillaries at which it arrived ; if it 
was injected into tributaries of the portal vein, the abscesses were found 
in the liver ; if into veins of the general system, the abscesses were 
in the lungs. Pyaemia follows the same law, however, less closely ; it 
is very common to find numerous abscesses in the liver when pus can 
only have been conveyed from the veins of the general system : on the 
other hand, that which is carried by the portal vein to the liver often 
seems to be entirely arrested there. There is no doubt that it is the 
presence of puriform matter in the blood which gives rise to the pheno- 
mena we are considering, but it is not yet fully ascertained whether 
perfectly-formed pus circulates in the blood, or only a pyogenic fluid, 
nor how either of these is introduced within the vessels. Before we 
enter further on these points, we will describe more particularly the for- 
mation of the multiple abscesses. M. Lebert, whose observations accord 
very closely with our own, notices particularly that the parts which are 
the seat of purulent effusion are truly inflamed; parenchymata, synovial, 
or serous membranes, if examined at all at an early period, are found in 
a marked state of inflammatory hyperemia. This proves that the term 
secondary depots, sometimes used, is incorrect ; the pus is actually 
generated, not only deposited in the part. The stages of the forming 
abscess are as follows : "(1.) A local and circumscribed capillary injec- 
tion, showing little vessels dilated and gorged with a dark red blood, 
more or less coagulated, in which are seen few globules, and very uni- 
form plasma, but never pus-corpuscles. (2.) In this centre of the vas- 
cularization a yellow point begins to be seen, which is nothing more 
than a drop of pus." The microscope shows in it some well-marked pus- 
globules, generally without nuclei, and especially many granules, all 
floating in a pyoblastic serum. (3.) The vascularity declines, the puru- 
lent collection increases, infiltrating the tissue, the elements of which 
are not destroyed. (4.) The secretion of pus continues, and the puru- 
lent inflammation is transformed into an abscess, bounded by a margin 
of red injection, and having its interior, in the case of the larger ones, 
lined by a soft pyogenic membrane. The larger abscesses have com- 
monly a very irregular form, which results from the fusion of several 
smaller ones together, as they go on increasing in size. As showing the 
truly inflammatory character of the pus-secreting process, we may men- 
tion that we have found the texture of the cartilage of the knee-joint 
10 



146 PYEMIA. 

altered just as it is in common arthritis with ulceration after death from 
pyaemia of only a few days' duration. The cartilage in the case referred 
to was ulcerated, and the joint contained pus. M. Lebert has made 
several careful observations, with a view to discover whether the pus- 
globules are actually present in the blood of the pyaemic; the result 
of these seems to be, that they cannot certainly be detected; even in 
the blood of animals that died from the effects of pus injected into their 
veins, the globules of pus could only once be discovered; and it seems 
incontestable, that in the great majority of cases they are rapidly de- 
stroyed after having entered the circulation. This throws considerable 
doubt on the view above noticed, that the pus-globules become arrested 
in the capillaries, in consequence of their size, and thus establish nume- 
rous foci of inflammation. Rokitansky also expresses his opinion very 
strongly against it. He considers that pyaemia occurs not uncommonly 
as a primitive affection; that is to say, that pus is actually formed by 
and in the blood itself, in consequence of certain changes in the fibrin, 
such as occur in the croupous crasis, which we shall afterwards notice. 
This supposition would account for cases occasionally met with, in which 
there are multiple abscesses, yet no source of purulent infection can be 
discovered. The more common case of consecutive pyaemia, he states, 
may originate in either of the three following ways, (a.) By the ab- 
sorption of the serum of pus, either into the lymphatics, or into the 
bloodvessels directly, (b.) By the reception of pus into bloodvessels 
which have been in any way opened, especially into those which traverse 
solid formations in which the mouths of the vessels are likely to be held 
open, (c.) Particularly by the flowing off towards the veins of pus, 
which has been produced in a local process (capillary phlebitis) within 
the vessels. We think it important to recognize the possibility of pyae- 
mia taking place from absorption of serum alone, because it is clear that 
this may easily take place wherever capillary vessels are in contact with 
puriform exudation. The reason why it does not more often occur is, 
we conceive, that in a tolerably healthy state the fluid absorbed from 
the pus is not adequate to contaminate the mass of the blood ; it under- 
goes certain chemical changes, and is soon eliminated as effete matter. 
But in a depressed state of the vital powers, the blood cannot resist and 
throw off the contaminating matter, and a pyogenic diathesis is esta- 
blished. This opinion seems to be confirmed by the experiments which 
have been performed upon animals. Lebert found that rabbits which 
had serum of pus injected into their veins, did not survive much longer 
than those in which pus was injected entire, but that dogs showed no 
serious morbid symptom after the injection of serum. In the experi- 
ment performed by Mr. H. Lee, we find that dogs and asses recovered 
from the effects of the injection of pus, or at least were recovering when 
the injection was repeated. All this shows that the weaker the system, 
the less it is able to resist the poisonous effects of pus, or its constituent 
parts; and should lead us to guard, as far as possible, against the super- 
vention of pyaemia after operations on debilitated patients. The third 
mode by which pus comes to be mingled with the blood is undoubtedly 
the most common, and is believed by Lebert to be almost the sole one. 
He remarks that, in the great majority of cases, some trace of inflam- 



LEUCOCYTH^MIA. 147 • 

raation of the veins may be discovered, and supposes that where they 
cannot, the veins affected are so small, or so obscured, that the source of the 
disease is overlooked. We believe that in such cases, pyaemia originates 
in either of the two other modes. The injection of pus into the living 
blood tends, as Lebert states, to diminish its fibrin, to destroy its glo- 
bules, to alter its normal cohesion, and to precipitate a part of its fatty 
principles. The blood thus altered tends to form ecchymoses, capillary 
hemorrhages, especially in the lobules of the lungs. Rokitansky de- 
scribes the bodies of those dead with pyaemia, as presenting only a brief 
rigor mortis, a lax and pale condition of the muscles, especially discolo- 
ration and lacerability of that of the heart, rapidly advancing putrefac- 
tion, with extensive stains from exudation. The lungs are especially 
the seat of dark hypostatic congestion. The coagula of the blood in 
the heart and large trunks are small and soft, and the inner membrane 
of the vessels stained. It is very intelligible how blood thus vitiated 
should tend to stagnate at various points of the capillary plexuses which 
it traverses, and to form there minute abscesses, without supposing that 
the vessels are actually blocked up by entire pus-globules. The obstruc- 
tion is of a chemico-vital, not of a mechanical origin. 1 The contami- 
nation of the blood when effected, is clearly of such a nature, that it 
determines the rapid suppuration of all exudations ; there is a strong 
tendency to the formation of pus, a true pyogenic diathesis. Were it not 
for this, the formation of the multiple abscesses would not take place so 
quickly. The fact stated by M. Lebert is interesting, that muco-pus, 
the product of an inflamed mucous membrane, produces, when injected 
into the blood, the same effect as pus, a further proof of the identity of 
the corpuscles of the two fluids. 



LEUCOCYTES MI A — LEUKH^MIA. 

These terms — the former signifying white cell-blood, the latter, 
simply white blood — have been given to a condition of the circulating 
fluid, which is not of very common occurrence, and has only been re- 
cently discovered. The former name is the more correct, as the blood 
does not lose its red color, and as the prominent alteration in it is the 
great increase of corpuscles, resembling the white or colorless ones 
naturally present. When a drop of blood, drawn during life, is ex- 
amined microscopically, the red corpuscles appear tolerably natural, 

1 In the following case, the formation of the secondary depots seems to have depended 
on a coagulation of the blood in certain spots, with simultaneous exudation of fibrin. A 
girl, aged nineteen, died after nine days' illness, having been previously in perfect health. 
There was purulent matter in and around several of the articulations. The lungs con- 
tained several masses, mostly about the size of a pea, and situated near the surface. 
Some were dark red, well-defined, and' exhibited under the microscope fibrin in strands, 
together with numerous blood-globules, granular cells, and celloid particles. Others ap- 
peared as whitish defined masses, showing scarce any trace of fibrinous coagulum, bat 
multitudes of well-shaped nuclei, and celloid particles, not resembling pus-globules, with 
some oily and granular matter. In others, again, the central part was softening down, 
while the outer remained firm, the central softened part never contained pus, but granular 
and oily matter with varying quantities of corpuscles. The most advanced presented a 
capsule of firm grayish indurated matter, with soft broken up contents. 



148 LEUCOCYTHJEMIA. 

and often arranged in rouleaux, leaving intermediate spaces, which are 
more or less crowded with the white corpuscles. It is difficult to say 
what is the proportion which the one set of corpuscles bear to the 
other. In the case which we witnessed, we should have regarded them 
as nearly equal, comparing mass to mass. Dr. Bennett estimates the 



Blood in Leucocythsemia — four of the white corpuscles hare heen treated with acetic acid. 
From Dr. H. Bennett's work. 

white as scarcely one-third the number of the red. Many of the white 
corpuscles are very much larger than the natural size. They have 
more coarsely granular contents than the normal ones, with an interior 
single, double, or tripartite nucleus. The envelop and nucleus are 
brought into view distinctly by the action of acetic acid, which renders 
the granular contents transparent. Occasionally, a crescentic nucleus 
is to be seen in the cells, and some free nuclei are also observed be- 
tween them. The blood, in fatal cases, is often found imperfectly 
coagulated — sometimes grumous, of a dirty brown color. The coagula, 
where decolorized, have not the aspect of healthy fibrin, but are of a 
more opaque dull yellow ; and, when broken up, resemble thick creamy 
pus. They contain in this part very numerous white corpuscles, to 
which the peculiar aspect is probably due. In the case where the 
blood has been analyzed, the fibrin exceeded the normal amount. 
Perhaps this increase may be rather apparent than real, in consequence 
of numerous white corpuscles being included in the fibrin. The red 
corpuscles are invariably diminished; the solids of the serum little 
altered. Morbid changes are chiefly observed in the spleen, the liver, 
and the lymphatic glands. The spleen is often very greatly enlarged, 
apparently by a kind of true hypertrophy of its nuclear structure. It 
has, however, been found healthy. The liver is less frequently en- 
larged. It was so in about half the number of cases. Its texture is 
more or less altered. The lymphatic glands seem to have been en- 
larged or cancerously diseased in eleven out of nineteen cases. The 
affection has been more often observed in males than females, in the 
ratio of 16 : 9. It seems " to be most common in adult life, and more 
frequent in advanced age than in youth." The respiration is often in- 
terfered with by the distension of the abdomen. Diarrhoea is a fre- 
quent symptom, vomiting is less often present. Hemorrhage, from 
various parts, was observed in the majority of cases, and was attended 
with purpura hemorrhagica in one instance. In about half the number 
of cases observed, dropsy was present, generally dependent on the ab- 
dominal tumors. Some febrile disturbance is not unfrequent, but not 



XECR^MIA. 149 

to any great degree, or of long continuance. Anaemia is commonly 
well marked, and emaciation, in the fatal cases, is said to be extreme. 
There seems no reason to believe that the affection is at all connected 
with ague, or the malarious poison. The foregoing facts, relative to 
Leucocythsemia, we have taken from the memoir of Dr. Hughes Ben- 
nett, who offers the following theory of its nature : He regards the 
spleen, thyroid, supra-renal, pituitary, pineal, thymus, and lymphatic 
glands, as constituting a great glandular system, whose office it is to form 
the blood-corpuscles. These are for the most part thrown off from the 
organs mentioned, and enter the circulation as colorless nuclei, identical 
with the peculiar corpuscles of these glands. Sometimes, however, the 
nuclei proceed to cell development, and appear then as the "white cor- 
puscles." The nuclei of these multiply by a process of division, circu- 
late in the blood with colorless cells, and subsequently escape and 
become colored blood-globules. Now, "in certain hypertrophies of the 
lymphatic glands," Dr. Bennett believes, that "their cell-elements are 
multiplied to an unusual extent, and under such circumstances find their 
way into the blood, and constitute an increase in the number of its 
colorless cells. This is leucocythsemia." Our limits forbid discussion ; 
and we can only say, that all our observations respecting the develop- 
ment of the red globules are entirely opposed to the view maintained 
by Dr. Bennett ; and that we are fully convinced that, whatever action 
the glands referred to exert upon the fluid part of the blood, they 
furnish none of its corpuscular elements. The blood, we believe, forms 
its own floating cells, and these may, of themselves, become diseased 
and variously altered. Neither can we admit that the external simi- 
larity of the white granular cells in leucocythasmia to the natural white 
corpuscles, is a certain proof of the one being merely further develop- 
ments of the other. Cells of similar aspect may have the most differ- 
ent properties. No other conclusions can be formed at present, as we 
think, than that leucocythsemia is a peculiar blood disease, whose 
cause and mode of origin is quite unknown. 



NECR^MIA. 

This term is applied by Dr. Williams to that condition of the blood, 
in which it appears to be itself primarily and specially affected, and to 
lose its vital properties. It is, in fact, " death beginning with the 
blood." "The appearance of petechiae and vibices on the external 
surface, the occurrence of more extensive hemorrhages in internal parts, 
the general fluidity of the blood, and frequently its unusually dark or 
otherwise altered aspect, its poisonous properties, as exhibited in its 
deleterious operation on other animals, and its proneness to pass into 
decomposition, point out the blood as the first seat of disorder ; and, by 
the failure of its natural properties and functions, as the vivifier of all 
structure and function, it is plainly the medium by which death begins 

in the body." " The blood, the natural source of life to the 

whole body, is itself dead, and spreads death, instead of life. The 
heart's action is faltering and feeble ; the atonic vessels become the 



150 CEASES OF THE BLOOD. 

seat of congestions, and readily permit extravasations. The brain, in- 
sufficiently stimulated after slight delirium, lapses into stupor ; the me- 
dulla no longer regularly responds to the a besoin de respirer," and the 
respiratory movements become irregular. Muscular strength is utterly 
lost ; offensive colliquative diarrhoea, or passive intestinal hemorrhage, 
often occurs ; sloughy sores, or actual gangrene of various parts is very 
easily produced ; and putrefaction commences almost as soon as ever 
life is extinct. The track of the superficial veins is marked by bloody 
stains; hypostatic congestion takes place to a great extent; the blood 
remains fluid, and stains the lining membrane of the vessels. Roki- 
tansky describes the blood as often foamy, from the development of 
gas — of a dirty red raspberry-jelly color ; its serum dark, from exuded 
hsematin ; and its globules swollen up by endosmosis. Coagula are 
either totally absent or are very soft and small. The exudations are 
of a dirty red — turbid, thin. There is scarce any rigor mortis ; the 
tissue of the heart and of other organs is flaccid and softened, and 
stained by imbibition of the serum. Gas is quickly formed in the ves- 
sels and in the areolar tissue, giving rise to a kind of emphysema. It 
is very remarkable that this necrsemic condition, or one closely resem- 
bling it, may be brought on by violent shocks inflicted on the nervous 
system, as well as by the introduction of miasmata or animal poisons 
into the circulation. Violent convulsions, overwhelming emotions, the 
shock of an amputation, a stroke of lightning, even a severe exhausting 
labor, are mentioned by the German pathologist as having produced 
this effect. More common causes, however, are malignant scarlatina 
and typhus, yellow fever, the plague, and the disease called glanders. 
It may be said, generally, that the early appearance of sinking and 
prostration in any fever indicates that the blood is thus seriously affected. 
We are ignorant what is the exact nature of the changes which take 
place in this condition of the blood. Probably they are more of a vital 
than merely chemical kind — •'that is, they affect the properties of the 
blood more than its composition. The blood-globules do not appear to 
be destroyed, but they circulate probably some time before death, as so 
many dead particles prone to be enlarged and to stagnate in the capil- 
laries, and to part with their contained hsematin. The fibrin is in 
great part destroyed ; but how this comes to pass we are ignorant. We 
can perceive, on the whole, scarce anything more than that the powers 
of vital chemistry rapidly decay, and those of ordinary chemical affinity 
usurp their place. 



CHASES OF THE BLOOD. , 

There are yet several morbid conditions of the blood which are scarce 
recognized sufficiently, at least among British Pathologists. These, 
Rokitansky describes as so many erases or alterations of the natural 
composition or mixture of the blood. They are often chronic, coming 
on imperceptibly, and, perhaps, scarcely noticed, until disorder begins 
to manifest itself in some particular organ ; in other instances, probably 
as numerous, their development and manifestations take place rapidly, 



CEASES OF THE BLOOD. 151 

and give rise to acute affections. There is very much reason to believe 
that they originate most of the serious visceral diseases which are so 
common. Very many cases of granular degeneration of the kidney, of 
cirrhosis of the liver, of contracted orifices of the heart, proceed, in our 
opinion, from slow and gradual textural changes, dependent on an 
unhealthy crasis of the blood. The importance of being aware of this, 
in the treatment of these affections, is abundantly manifest. As, how- 
ever, our knowledge of these conditions of the blood is yet very imper- 
fect, we shall not attempt more than to indicate shortly the principal 
features of the several erases, as they are enumerated by Rokitansky : 
A crasis may occur as the primitive affection, and its local manifesta- 
tion, when it takes place, be determined, as to its seat, either by external 
influences, or by the operation of the nervous system. Or it may be 
consecutive, arising as the consequence of a local, morbid process, which 
has caused infection of the general mass of the blood by matter absorbed, 
or having undergone a deteriorating change within the vessels. A 
crasis may terminate, either by return to the healthy condition, or by 
conversion into another morbid crasis, or by destruction of life. 

The fibrinous crasis corresponds to the condition of blood, which may 
be termed phlogistic or inflammatory. It is characterized by an in- 
creased tendency of the fibrin to coagulation, and to separation in a 
solid form, either in some part of the vascular system, or as an exuda- 
tion in some of the tissues. For the development of this crasis, Roki- 
tansky considers it necessary that the respiratory function should be 
freely performed. In most cases, the quantity of fibrin in the blood is 
much increased; but this is not so essential a feature as the alteration 
of its quality. In the croupous variety of this crasis both the coagula 
and the exudations show less tendency to organization ; on the contrary, 
they tend to break up themselves, and often corrode, and, as it were, 
fuse down the tissues in which they are deposited. The mucous surface 
of the respiratory and digestive canals, serous and synovial membranes, 
are the chief seats of such exudations. The croup of early life, many 
pneumonias, many cases of puerperal peritonitis or phlebitis, acute 
rheumatism, and endocarditis, are so many examples of disease inti- 
mately connected with this crasis. Fibrinous erases often appear 
epidemically. It may be fairly asked, whether the condition of the 
blood may not be always produced by the inflammation. We are, how- 
ever, quite of Rokitansky's opinion, that while, in many instances, there 
is no doubt that such is the case, yet that there are numerous others in 
which the local inflammation is the result of a foregoing crasis. The 
marked disproportion that is sometimes observed between the hyperaemia 
and the exudation, and the early occurrence of the latter in many cases, 
appear to us to argue strongly in favor of this view. 

Rokitansky recognizes an aphthous variety of the fibrinous crasis, 
which gives rise to the exudations of muguet, diphtheritis, some dysen- 
teries, and of hospital gangrene. These are manifestly outpourings of 
deteriorated diseased fibrin on various surfaces, rather than products of 
local inflammation. The alteration of the blood in these instances 
must certainly be primary. 



152 



THE TUBERCULOUS CRASIS. 



THE TUBERCULOUS C RASIS— TUBERCLE 



The product of this crasis, from which it has its name, is the well- 
known substance, which, on account of its frequently spherical shape, 
is called tubercle. This we have not yet described ; and though Roki- 
tansky places it among the organized new formations, yet we think 
it will be more convenient to make mention of it here, in connection 
with our remarks upon the condition of the blood in which it originates. 
Tubercle, or tuberculous matter is, in almost all cases, an exudation 
of protein material, which speedily passes into the solid form, and never 
proceeds beyond the lowest grade of development. It very commonly 
assumes a spherical shape, which appears to depend partly upon its en- 
larging from its original magnitude by successive accretions to its surface, 
and partly on the nature of the tissue in which it is deposited. There 
are two principal varieties of tuberculous matter, distinguished as gray 
and yellow tubercle. The former, sometimes 
called gray granulations, are about the size of a 
millet-seed, roundish, resisting under pressure, of 
a grayish, semi-transparent aspect. The micro- 
scope shows them to consist of a basis-substance 
(blastematous), which is solid and homogeneous, 
and serves as the uniting medium of certain cor- 
puscular elements. These are granules commonly 
of oily aspect, nuclei, oval, or more elongated, 
generally feebly formed, and cells, which are, for 
the most part, very few in number, and probably 
not to be regarded as any essential part of the 
tubercle itself. The globules of tubercle, which M. Lebert describes as 
characteristic of this morbid product, are nothing more than the ill- 



Fis. 28. 




Gray tubercle 
lation. 



miliary granu- 



Fig. 29. 







Yellow tubercle; crude mass. 



developed nuclei just mentioned. Rokitansky applies to them the fol- 
lowing epithets: " anomalously shaped, irregular, as if gnawed, angular, 
bent, constricted, rudimentary, stunted." The elements of the tissue in 
which it is deposited, are often found imbedded in the mass. This, 
however, scarcely applies, except to those which are not very readily 



THE TUBERCULOUS CRASIS. 153 

destroyed, as fibres. No vessels are ever found in separate tubercles; 
some traces of those belonging to the tissue may be imprisoned in the 
interspaces of several aggregated together. Yellow tubercle forms masses 
of varying size, but generally somewhat larger than those of the gray, 
equalling, perhaps, a hemp seed, or a pea, in magnitude. They are 
from the outset opaque, of a whitish-yellow color, of rather brittle con- 
sistence. Their microscopic structure is nearly identical with that of 
the preceding variety, only that they contain more diffused granular 
matter. Their relations, also, to the surrounding textures, are quite 
similar to those above mentioned. The yellow tubercle, which Roki- 
tansky denominates the croupo-fibrinous, in opposition to the gray, which 
is the simple fibrinous, undergoes two metamorphoses of very great 
importance; one is that of softening, the other that of cretification. 
Softening consists in the texture of the mass becoming more lax and 
moist, with notable increase of size, the change proceeding till it breaks 
up into a yellowish, diffluent, cheesy mass, which finally becomes a thin, 
whey-like fluid, of acid reaction, containing minute flocculi. The phange 
seems first to affect the homogeneous basis-substance, which dissolves into 
a kind of fluid, loaded with pulverulent molecules; the corpuscular ele- 
ments in consequence of this are set free, and, at the same time, are them- 
selves more or less corroded and dissolved. The softened tubercle thus 
consists of (1) a fluid loaded with diffused granulous matter; (2) traces of 
altered nuclei and cells; (3) free oil in 
the form of various-sized drops. It may Fi g- 30. 

also contain debris of the tissues. The 
cretifying change consists in the gradual 

deposition and liberation of calcareous par- $f / P ^ ^ ^ &V/& ' iki °° 
tides in the tuberculous mass, together ~~^ & J ^@ 
with simultaneous absorption of the animal & * 

matter, and consequent decrease in size. Isolated tU bercie corpuscles, on the 
It is said by Rokitansky never to take place right are four Mood-giohuies. 

except in softening, or softened tubercle ; 

but this is, probably, too absolute an assertion. The cretified tubercle 
very often remains as a hard, irregular mass, surrounded by indurated 
tissue, and appears to be insusceptible of further change; sometimes, 

Fig. 31. Fig. 32. Fig. 33. 







•MM v& 



&8& - ,Q) 







' ;.;, v$ * '■;:[■;■ • 


9 Xv.fA ■;■■:: 




mT?M 




Fig. 31. Tubercle corpuscles from the peritoneum, a. The same, after the addition of acetic acid. 

Fig. 32. Tubercle corpuscles, granules, and molecules, from a soft tubercular mass in the lung. 250 

diameters linear. 
Fig. 33. Tubercle corpuscles, from a mesenteric gland. 



154 



THE TUBERCULOUS CRASIS. 



however, absorption proceeds further, and almost the whole of the de- 
posit is removed. When this is the case, however, it is probable that 



Fig. 34. 



Fig. 35. 



Fig. 36. Fig. 37. 



Fig. 38. 



S.S&! 










Fig. 39. 

■."°.'^5S>' 

ml 



Fig. 40. 



r-° - ' III 




Fig. 41. 



mmmam 



Fig. 34. Tubercle corpuscles from the lung. 

Fig. 35. Pus-corpuscles. One shows the double granular nucleus after the addition of acetic acid. 
Fig. 36. Plastic or pyoid corpuscles. 
Fig. 37. Granular corpuscles from cerebral softening. 
Fig. 38. Cancer-cells from the uterus. 250 diameters linear. 

Fig. 39. Structure of the central portion of a tubercular mass, imbedded in the cerebellum. 
Fig, 40. Structure of the external portion of the same mass, where it was in contact with softened cere- 
bellar substance. 250 diameters linear. 

absorption had predominated over the deposition of calcareous matter 
from the first. The only metamorphosis, accord- 
ing to Rokitansky, which the gray tubercle under- 
goes, is a kind of drying up into a hornlike sub- 
stance, which, in some cases, is also the seat of 
calcareous deposit. This he calls obsolescence. 
It has been very commonly held, since the time of 
Laennec, that the gray tubercle, or gray granu- 
lation, was the nascent phase of the yellow : Dr. 
Walshe, after careful examination, maintains this 
view ; Hasse and Rokitansky reject it. The latter 
regards the two as essentially distinct, though very 
frequently combined together in the same tubercle, 
in varying proportions ; and remarks, with much 
reason, that it is an error to look upon these dif- 
ferences in composition as stages of transition, or 
conversion of one into the other. The apparent 
softening of the gray tubercle, when it occurs, is not dependent upon 
an alteration in its own substance, but in that of the yellow mingled 
with it. It is very interesting to remark how the behavior of the two 
kinds of tubercle corresponds with that of the fibrin, from which they 
seem to be derived. The gray resembles healthy fibrin in its tendency 
to contract and shrink up into an indurated mass ; the yellow, like the 
croupous fibrin of coagula and exudations, tends to soften and break up 
into a fluid substance. Moreover, as the masses of croupous fibrin begin 




Fragments of phosphate of 
lime, crystals of cholesterin , 
and tubercle corpuscles, from 
a cretaceous mass in the 
lungs. 



THE TUBERCULOUS CRASIS. 155 

to soften in their central part, so we find does the yellow tubercle. Dr. 
Carswell and others consider that inflammation and suppuration taking 
place in the tissues surrounding the tubercles, are the chief cause of its 
softening and breaking down. This Rokitansky denies ; but though we 
believe with him that the softening change is one inherent in the tu- 
bercle-substance itself, yet we think the hypersemic movement taking 
place around it must, at least, give an impulse to the process. As each 
tubercle, or group of tubercles, undergoes softening^ the space which it 
occupied becomes the cavity of a minute abscess, the contents of which, 
sooner or later, are evacuated. The tissue involved in the tubercle is, 
of course, destroyed, together with it, but rather in the way of necrosis 
than of ulceration. The tendency of the tubercle to soften differs very 
greatly in different cases. Sometimes it is scarcely deposited before it 
begins to break down, sometimes it remains very long in its original 
(crude) state. The influence of the inflammation set up around tubercles 
upon their progress varies very much, chiefly according to the degree of 
the tuberculous dyscrasia. If this be very great, the result of the in- 
duced hyperemia will be the infiltration of the bordering tissues with 
tuberculous matter of the lowest kind, tending to rapid diffluence, and 
involving in its destruction that of the infiltrated tissue. The increase 
of a tuberculous cavity in this way may be most rapid. On the other 
hand (and herein is contained a truth of the utmost interest to the prac- 
titioner), if the dyscrasic condition of the blood be slight originally, or 
if it have been amended by well-directed treatment, inflammation gives 
rise to the exudation of fibrin, which develops itself into the so-called 
induration tissue, or fibroid callus, which either surrounds and capsulates 
the tubercle, or forms a wall to and contracts the cavity, if one has 
formed. The surrounding tissues are often much puckered by the shrink- 
ing in of the fibrinous deposit. There occur occasionally, especially upon 
serous surfaces, small granulations which have much the aspect of tu- 
bercles, but which, in their progress, assume more of a fibroid texture ; 
these may be regarded as specimens of an intermediate condition be- 
tween tubercle and fibrinous exudation, and are, in this light, of great 
interest. Tubercle seems sometimes to be deposited in the way of 
infiltration; that is to say, it no longer forms the small characteristic 
tubera, from which its name is derived, but appears as a uniform mass 
which had been effused into the tissue in a fluid state, and had soli- 
dified there. The common tuberculization of the absorbent glands is 
very much of this kind ; it is seen, however, most strikingly, in the 
lungs, a whole lobe or more of which may appear to be converted into 
a tuberculous mass. Sometimes this appearance depends on the part 
being occupied by numerous tubercles, crowded together; but then 
there can always be distinguished on a section interposed layers of pul- 
monary tissue which are not seen in real infiltration. The only doubt 
as to the real nature of apparent tuberculous infiltration arises from the 
great similarity between chronic pneumonic consolidation and this state, 
so that Dr. Walshe is inclined to consider them identical. Our own 
belief is, that in a person whose blood is in a high degree affected by 
the tuberculous dyscrasia, inflammatory hyperemia may result in the 
exudation of a material which corresponds closely with tuberculous, but 



loQ THE TUBERCULOUS CRASIS. 

is less inclined to soften and break down. The seat of tubercle in the 
vast majority of cases is on the exterior of the vessels, but in their 
immediate neighborhood ; its blastema is a true exudation, but, inasmuch 
as it coagulates with great rapidity, it is not able to penetrate for any 
distance through the substance of a non-vascularized tissue. Hence, we 

Fisr. 42. 



f Section of a gray granulation in the lung after the addition of acetic acid, showing the pulmonary 
air-vesicles filled with tubercle corpuscles. 250 diameters linear. 

do not find tubercle in cartilage. In very rare instances, coagula of 
tuberculous character have been seen within the vessels ; but these, no 
doubt, underwent a morbid alteration after being formed ; and there is 
not the least evidence to show that anything resembling tuberculous 
matter has even been detected in the blood. The microscope can dis- 
cover nothing peculiar in the blood of phthisical patients, nor has 
chemistry detected any characteristic alteration in its protein com- 
pounds, which we might reasonably expect to find primarily affected. 
The exudation of tubercle-blastema may take place most gradually and 
imperceptibly, with scarce a trace of constitutional disturbance, or it 
may occur in a rapid, tumultuous manner, with all the symptoms of an 
acute illness ; between these extremes the most various grades are 
observed. The more rapid the deposition of tubercle, the more is it 
associated with hyperemia and inflammation. In fact, though the 
production of tubercle be quite independent of inflammation, and though 
inflammation, in the great majority of cases, is only secondary, and 
excited by it, as a cause of irritation, yet, when set up, it has a powerful 
effect in hurrying the exudation of tubercle, and that of such a kind as 
tends to rapid softening and decay. Commonly, the gray tubercle is 
the first to appear; sometimes, however, the yellow, in the miliary dis- 
persed form; afterwards, as the dyscrasia increases, the exudation con- 
sists of yellow tubercle mingled with the gray ; and, finally, of yellow 
tubercle alone. Tubercle may be deposited, we believe, in extravasa- 
tions of blood, or, at least, its blastema may be mingled with blood ; 
the changes which the latter undergoes, suggest to Kokitansky the 



THE TUBERCULOUS CRASIS. 



157 



Fig. 43. 



Corpuscles mixed with pig- 
mentary matter, in a small 
tubercle taken from the peri- 
toneum, a. Irregular masses 
of black matter, which may 
be broken down into (b) gra- 
nular and molecular matter. 
250 diameters linear. 



name of pigmentary tubercle, as distinguishing it from the more common 
varieties. Melanic matter, however, is often found, in small quantity, 
in the latter also. The following remarks are of 
much interest and importance relative to the co- 
existence of tuberculous disease with other affec- 
tions. 

Cystic growths are not often associated with 
tubercle, and the same is true of cancerous ; when 
the latter are present together with tubercle, they 
are, in most cases, of secondary origin to it. 
Rokitansky contrasts the frequency of tuberculiza- 
tion of the lungs with the rarity of pulmonary 
cancer; the frequency of ovarian, gastric, and 
rectal cancer, with the rarity of tuberculous de- 
posit in these parts. These and other facts indi- 
cate that the one morbid process tends to exclude 
the other. Typhus and the exanthemata, he 
states, do not commonly attack the tuberculous, 

but they are very apt to be followed by tuberculous disease. Sufferers 
from intermittent fever, goitrous disease, and rachitis, seem to be, pro 
tanto, less liable to tuberculous affection. The non-coexistence of aneu- 
rismal and tuberculous disease depends, in Rokitansky's opinion, on the 
exhaustion of the fibrinous constituent of the blood, by the deposits 
taking place on the inner surface of the sac. An especial immu- 
nity against tubercle is afforded by an abnormally venous condition of 
the blood, from whatever cause this may come to pass. Congenital 
malformations of the heart or great bloodvessels; morbid alterations of 
the same ; deformities of the chest, producing contraction of its cavity; 
annihilation of the function of one lung by pleuritic 
effusion ; abdominal growths, preventing the free 
descent of the diaphragm ; chronic pulmonary 
catarrh ; emphysema and bronchial dilatation, have 
all been observed as exercising an unquestionable 
counter influence against the development of tuber- 
cle ; and in all these conditions the free oxygena- 
tion of the blood is more or less interfered with. 
The undoubted effect of pregnancy in delaying the 
advance of tuberculous disease of the lungs, is explained by Roki- 
tansky on the same principle of impeded, and consequently imperfect 
respiration, inducing a venous condition of blood; and he refers to 
the great production of fibrin, which takes place after parturition, 
as confirmatory of this view — tubercle being regarded as a fibriniform 
product. Respecting the identity of tuberculous and scrofulous matter, 
there can be no doubt. They have the same elementary composition, 
they undergo the same changes, they are produced in the same way, and 
produce the same effects on the tissues in which they are deposited. 
Generally, it may be said, that the deposit in the absorbent glands and 
bones passes for scrofulous; that in the lungs or brain, for tuberculous 
matter — both being essentially what we have described as vellow tuber- 
cle. The name seems to depend almost entirely upon the form. In 



Fig. 44. 




©®'3 



Scrofulous matter from 
subcutaneous deposit. 



158 



THE TUBERCULOUS CRASIS. 



adults, tubercle is found in the various organs in about the following 
scale of frequency: Lungs, intestinal canal, lymphatic glands (especially 
the abdominal and bronchial), larynx, serous membranes, brain, spleen, 
kidneys, liver, bones, and periosteum, uterus and Fallopian tubes, testi- 
cles (with the prostate gland and vesiculse seminales), spinal cord, 
voluntary muscles. In children, Rokitansky states, the lymphatic 
glands and spleen are most often affected, then the lungs, and after 
these the brain, &c. MM. Rilliet and Barthez assign, as in adults, the 
primary place to pulmonary tubercle. According to them, however, the 
lungs are not so invariably affected as M. Louis's well-known law declares 
them to be in adults; as, in forty-seven out of three hundred and twelve 
instances, they were exempt, while tuberculous deposit was found in 
other organs. It is to be observed that the above scale of frequency 
of the occurrence of tubercle in adults does not express correctly the 



Fig. 45. 



Fig. 46. 



©3 










$ © 



Scrofulous pus — a large glomerulus is shown, and 
some oil drops. 



•t#f 



Scrofulous pus from a lymphatic 
gland. 250 diameters linear. 



different tendency of the various organs to primary tuberculosis. Roki- 
tansky places in this respect the lungs and lymphatic glands first, then 

the urinary organs, the bones, the testicles, 
&c. ; while the intestines, the larynx, the 
spleen, and the liver, occupy the lower part of 
the scale. The question as to how far, and in 
what way tuberculous disease is curable, is of 
course of the greatest interest. As an exuda- 

Jtion, it seems credible that tubercle should 
' ^-'\%Pp£%^$> ^quefy and undergo absorption; but it has been 
'^SMSk'hS^M^Sx very generally doubted whether this ever ac- 
tually occurs. Dr. Walshe, whose authority 
is great on this point, believes that absorption, 
under favorable circumstances, may take place, 
but acknowledges it to be a rare event. Pro- 
bably the most favorable result that can gene- 
rally be expected, after tubercle is once deposited, is either that it 
should cornufy simply without having undergone softening, or that after 
this change it should cretify. After tubercle in any quantity has soft- 
ened, and a cavity been formed from which the tubercular detritus is 
afterwards eliminated, a cure may still take place ; but it is a much 
rarer occurrence than in the two former cases, and perhaps never 
attains to the complete closure and cicatrization of the cavity. This, at 
least, applies to the lungs; in other parts, there is no doubt that a 
tuberculous ulcer may heal up and cicatrize. The production of tuber- 




Pus from a scrofulous abscess. 



THE TUBERCULOUS CRASIS. 159 

cle sometimes takes place, as observed above, with very great rapidity, 
constituting what is termed acute tuberculosis. It is remarkable that 
the symptoms in this condition very closely resemble those of typhus 
fever (v. case in Dr. Walshe's work on Diseases of the Lungs and Heart, 
p. 409). The tubercle is of the gray miliary kind, is widely and uni- 
formly scattered throughout the lungs, and is often deposited in other 
parts also. 

As a sequel to the foregoing account of tubercle, we may describe here 
a somewhat analogous deposit, which is not very unfrequently found in 
the organs of those who are the subjects of general cachexia. It appears 
as a solid blastematous mass, infiltrated among the tissues of a part ; semi- 
transparent, or verging on a whitish opacity — presenting, under the 
microscope, an amorphous, flaky basis-substance, together with scanty 
nuclei. It is commonly deposited in a part in considerable quantity, 
and gives rise to the appearance of hypertrophy, though at the same 
time the natural elements of the tissue are compressed and atrophied, 
often to a great extent. An organ thus affected is bloodless, breaks 
with a sharp fracture, and strongly resembles bacon in appearance, from 
whence the term "bacony" is applied to the deposit by German writers. 

The formation of this matter is not peculiar to the scrofulous diathe- 
sis, but it is observed in those who have become cachectic from any 
cause; as from the abuse of mercury, inveterate syphilis, habitual inter- 
mittents, or any severe drain upon the system. Rokitansky calls the 
deposit " albuminous raw blastema," and believes it to proceed from an 
undue quantity of albumen being present in the blood. 

With respect to the real nature of the tuberculous crasis, we have 
scarce any exact knowledge. It is evidently a special dyscrasia, inti- 
mately connected, as we know, with causes of debility, and leading to 
the effusion of a matter, which shows only the feeblest traces of organi- 
zation. This matter in many respects comports itself very differently 
to fibrin ; so much so, that the one might almost be regarded as the an- 
tithesis of the other — supplanting it in the process of effusion, or itself 
replaced by it. Rokitansky, however, shows some weighty reasons for 
regarding tubercle as a modification of fibrin; and after a most interest- 
ing discussion, to which we would particularly refer (v. p. 522, German 
edition), concludes that "the arterial character — arterial elaboration of 
the fibrin — constitutes, above all, the cardinal feature of the tuberculous 
crasis." He also points out how, in consequence of the alteration of 
the nature of the fibrin, tubercle is continually deposited, even when the 
blood is very deficient in that constituent. All the fibrin that is formed 
is soon affected by the peculiar dyscrasia, and is thrown out in the form 
of tubercle. The rapid coagulation of tubercle-blastema, which must be 
effused in a fluid form, its tendency, when coagulated, to soften — its for- 
mation being favored by active arterialization, and prevented by a 
venous condition of the blood — are circumstances which indicate a real 
affinity between tubercle and fibrin. When we further reflect that 
various debilitating causes are found to increase the quantity of fibrin, 
and also that the same'are potent in causing the production of tubercle, 



160 THE TUBERCULOUS CRASIS. 

we gain further evidence to the same effect. No doubt, however, even 
before that peculiar modification of the fibrin has occurred, which leads 
to its excretion in the form of tubercle, a special impress is, at least in 
many cases, stamped upon the system, which betrays to the instructed 
eye the future evil. The tendency and proclivity to disease is there, it 
may be, long before its actual development. This unexplained proclivity 
it is which constitutes the scrofulous diathesis. 

A condition of the blood, characterized by deficiency in fibrin, excess 
of albumen, and for the most part also of blood-globules, is termed by 
Rokitansky venosity, or albuminosis. Simon designates it hypinosis, 
in contrast to hyperinosis, which implies an excess of fibrin. Rokitansky 
describes under this head several erases, in which the blood partakes of 
the hypinotic character; but we shall do no more than enumerate them, 
as we think he ascribes far too much to the apparent qualities of the 
blood, and does not take sufficient count of the unseen but essential de- 
rangements: "Hypinotic blood is in general a thick, sticky, dark red 
fluid; contains no coagula, or only small, soft, sticky, gelatinous ones, 
which include much cruor." It is apt, under peculiar circumstances, to 
undergo various changes, such as septic destruction of the albumen, in 
which case necrsemia takes place; or a croupo-fibrinous or pysemic con- 
dition may supervene ; or a tendency to the effusion of acid fluids and 
acute softening of tissues. Dark hypostatic stains, speedy putrefaction, 
transitory rigor mortis, a lax state of the solids, are observed in the 
bodies of those who die with this condition of blood. 

The subordinate hypinotic cases are — (1) plethora; (2) the typhous; 
(3) the exanthematic; (4) that existing in certain diseases of the nervous 
system; (5) drunkard's dyscrasia; (6) cancerous dyscrasia. 

We may mention, with regard to the drunkard's dyscrasia, that, when 
chronic, it presents a remarkable dark color, and inspissation of the 
blood, with excessive quantity of oil. Fat is formed abundantly in the 
subcutaneous tissue, and in other parts. The liver, the muscles, and 
even the bones are either encroached on by the fat, or undergo some 
degree of fatty degeneration. The cerebral membranes are apt to be- 
come thickened, the brain itself to be atrophied. Chronic fluxes, from 
the mucous membranes, especially the bronchial and intestinal, are very 
common. The crasis often undergoes change to the croupo-fibrinous. 

We would recommend the doctrine of erases of the blood to the careful 
thought of our readers. No doubt it may easily be carried too far; but 
we think cases will often present themselves, in which an apparent 
inflammation and manifest exudation will be better explained and man- 
aged by the ideas which this doctrine suggests, than by the most vigorous 
anti-phlogistic proceeding. 



CHAPTER III. 

TEXTURAL CHANGES. 

We now come to consider certain changes, to which most of the 
various organs of the body are liable, in a general way. These changes 
are essentially textural, and result from various disturbances of the 
normal degree and kind of nutrition. They are also for the most part 
slow and gradual in their course, and are thus termed chronic. They 
are intimately dependent on the condition of the blood, so that their 
consideration follows very properly on that of the diseases of this fluid. 

Hypertrophy, as its etymology signifies, conveys the idea of increased 
nutrition and growth in the part affected. The term, however, is some- 
times applied to parts which are simply enlarged, and it is essential 
to observe that this enlargement by no means necessarily constitutes 
hypertrophy, but may, instead, be attended with the opposite condition. 
This makes it necessary to distinguish real from apparent hypertrophy. 
In the former, the characteristic tissue of the part is enlarged, and more 
developed ; if it be a muscle, the muscular fibres grow larger, and attain 
to greater energy of contraction, if it be a kidney, more renal tubes are 
formed with corresponding bloodvessels. The size of the organ is not 
only increased, but its working power too ; the muscle can raise a greater 
weight, and the kidney can produce more secretion. But if a liver or 
spleen be enlarged by ever so great a quantity of the peculiar matter 
termed "bacony," which is deposited interstitially between the elements 
of the tissue, their functional power is only thereby lessened, and dete- 
riorated, for the simple reason that the new substance has pressed upon 
and caused wasting of the natural structure. It is, therefore, necessary 
in every case to ascertain what is the nature of the enlargement of a 
part before we pronounce it to be truly hypertrophied. Mere distension 
of a hollow organ, of course, is not , hypertrophy ; a huge emphyse- 
matous lung, or hydrocephalic brain are not really enlarged, but rather 
diminished in actual capacity. Great congestion of a part with blood 
may give it the appearance of being hypertrophied, but this again is 
only another kind of distension. Real hypertrophy requires a free sup- 
ply of healthy blood, and is commonly attended with enlargement of the 
vessels of the part ; this is not the case in apparent. The cause of real 
hypertrophy seems to be always the increased exertion of the organ, 
more than usual effort is demanded of it, and according to the law of 
the circulation which we have noticed, more blood flows to the part than 
usual ; this, if the organ be in a healthy state, not only supplies its 
waste, but furnishes material for increase and development. The heart 
11 



162 TEXTUKAL CHANGES. 

in various diseased states of its valves, the urinary bladder in stricture 
of the urethra, the remaining kidney when one has been destroyed, the 
muscles, and even the solid bones themselves, when long and actively 
exercised, afford excellent examples of true hypertrophy. 

This process, though in several instances it brings about an abnormal 
state of the part, is yet for the most part not to be considered in the 
light of a disease. It is really a compensatory effort made by the sys- 
tem, to obviate as far as possible the evils that arise from some damage 
that an important part has sustained. Thus, if we find the walls of the 
heart greatly thickened, and its power proportionately increased, we 
should naturally fear that such an abnormal increase of power would 
prove a cause of danger to the system, and would probably induce 
hemorrhage in the brain, or elsewhere ; but if we know that at the 
same time there exists regurgitant disease of the mitral or of the aortic 
valves, then, we see, that the hypertrophy, so far from being attended 
with danger, is useful and necessary to enable the circulation to be 
carried on against such impediments. 

Atrophy is the opposite condition to hypertrophy; and is commonly 
conceived of as implying a wasting and diminution of the part. 
Atrophy, however, may have taken place to a great extent, without any 
diminution, but an increase of size. These are the instances of false 
hypertrophy, to which we have above alluded. In a few instances 
atrophy is a natural process, as in the disappearance of the thymus 
gland when the age of early infancy is passed. Inactivity of a part, 
obstruction of its bloodvessels, failure of its own vital energy, continued 
pressure upon its surface, are all recognized causes of atrophy. A 
muscle, if unused, becomes small and pale, and its tissue degenerates ; 
the bones of a paralytic limb lose in density and strength, and in com- 
pactness of tissue ; the brain in second childhood shrinks within its 
bony case, and leaves a space occupied by serum. Obstruction of the 
arterial branch leading to a part of the kidney will cause wasting of the 
epithelium of the tube in that part, ligature of the thyroideal arteries 
has caused considerable diminution of a goitrous tumor. Thinning of 
the walls of the heart, renal degeneration, the fall of the hair, and the 
general decay of advanced age, are instances of atrophy from failing 
vital energy of the tissues. With the effect of pressure in producing 
atrophy, all are familiar ; it is well exemplified in the absorption that 
takes place from the pressure of aneurism, which affects not only the 
soft parts, but the bones themselves. In most cases, atrophy is an 
actually morbid process, and is attended by a change in the condition 
of the elementary parts of the tissue which attests the unhealthy cha- 
racter of their nutrition. Atrophy often occurs as a secondary process, 
induced by some primary one, which may have been attended with 
apparent hypertrophy. Of this, the liver in the earlier and later stages 
of cirrhosis furnishes an instance. 

Induration and softening, are terms that are commonly employed to 
express changes that have occurred in the consistence of various organs, 
rendering them more or less firm and dense than natural. They are, 
of course, very general in their meaning, and of themselves tell nothing 
as to the pathological condition of the part affected. This must depend 



TEXTTJRAL CHANGES. 163 

entirely on the causes of the changes in question. The commonest cause 
of induration is the effusion of fibrinous material into the interstices of a 
tissue; if this does not liquefy and become absorbed, it passes into the 
state of fibroid texture, and being blended with the elements of the part, 
it occasions a more or less considerable increase of density and tough- 
ness. Instances of this are extremely frequent in the lungs around 
tuberculous deposits, in the cirrhotic liver, and in the areolar tissue 
around ulcers. The tissues involved in the induration matter, as it is 
often called, are very apt to become atrophied, partly in consequence 
of their supply of blood being cut off by obliteration of the vessels dis- 
tributed to them, partly from the effect of atrophic pressure itself. 
According to its seat, induration may be of trifling consequence, or very 
serious; in the general areolar tissue of the body, it may only cause 
slight impediment to the free movements of a part; in the valves of the 
heart it is a common cause of secondary disease, dropsy, and death. 
Textures are often rendered harder and firmer by other deposits than 
simple fibrinous, as by tuberculous, bacony, calcareous, but to these the 
term induration is not so strictly applicable. 

Softening of a part may be brought about by very various causes. 
It is almost an invariable effect of acute inflammation actually existing ; 
it is also found as the result of inflammation that has in great measure 
subsided ; it occurs from deprivation of blood, as a kind of atrophy, and 
probably, in some cases, as a local result of a general cachexia. In all 
cases it involves a considerable deviation from the state of healthy nu- 
trition, and if it proceeds far, may easily occasion a breaking down and 
destruction of the tissue. The distinction of various kinds of softening, 
especially of the red, or inflammatory, has often been considered difficult, 
but may generally be made with certainty by means of microscopical 
examination, which discovers in the former decided traces of exudation. 
Softening is connected with the hypinotic condition of the blood, arid 
its subordinate erases, especially the typhous; induration, on the other 
hand, with the fibrinous crasis. Softening is more prone to occasion 
speedy destruction of textures and fatal disorder. Induration, to pro- 
duce gradual changes whose effects are slowly and gradually manifested. 
Softening appears as a process of decay, and affects not only natural 
structures, but new formations, and even as we have seen tuberculous 
deposits and fibrinous coagula. Induration, on the contrary, though 
involving some degree of atrophy, tends to preserve the parts which it 
affects from entire dissolution. 

Degenerations are changes of an essentially chronic nature, latent 
in their origin, and obscure in their progress, until they have produced 
such deteriorations of structure as give rise to prominent secondary 
phenomena. Those with which we are most acquainted are the fatty, 
fibrous, and calcareous. They are of extremely frequent occurrence, 
but their nature has scarcely been recognized until of late. 

Fatty degeneration consists in the replacement of the healthy tissue 
of a part, by drops, or molecules of oily nature, which are deposited, 
as it seems, instead of the natural material. This character distin- 
guishes it from fatty accumulation, which may take place to a great ex- 
tent in the interstices of a tissue so as to overlay and conceal its ele- 



164: TEXTURAL CHANGES. 

ments. In true fatty degeneration there is always destruction of tissue, 
which does not occur when there is merely an increase of oil in the sub- 
stance of the part. A muscular fibre thus affected shows the sarcous 
elements, the real contractile tissue within the sarcolemma, replaced 
by glistening oil-particles, so that the functional power of the organ is 
pro tanto destroyed. The hepatic cells in true fatty degeneration not 
only fill themselves with oil, but fuse together with others, and break up 
into granulous films, entangling oil-drops; this destruction does not occur 
when they simply become loaded with oil from the presence of a large 
quantity of this substance in the food. The process by which fibrinous 
coagula, or extra-vascular deposits are broken down and dissolved, seems 
to be in some measure of the nature of fatty degeneration ; there is com- 
monly much free oily matter visible in the softened mass, and the 
exudation corpuscles seem to be thoroughly charged with it. Fatty 
degeneration is clearly a kind of atrophy, but not identical with the 
simple form; we have seen muscular fibres of the heart which were 
simply atrophied, and had lost their transverse striation entirely, which 
yet did not contain a single particle of oil. The prevalent opinion re- 
specting the nature of fatty degeneration is, that there occurs a true 
conversion of the albuminous substance of the tissue into fatty matter, 
just as when adipocire is formed out of flesh immersed in water. We are 
rather inclined to believe that the change is effected in the way of an 
unhealthy nutrition, oil being deposited in the blood in the place of 
nitrogenized matter. However this may be, it is important to distin- 
guish the following conditions in which the quantity of fatty matter in 
and upon a part is greatly increased. (1.) Mere accumulation of 
adipose substance in and around an organ, the tissue remaining healthy, 
(2.) Accumulation of adipose tissue in the same way, but with atrophy 
of the proper structure. (3.) Increase of oil in the elementary struc- 
ture of a part without atrophy, or breaking up. (4.) True fatty de- 
generation, in which the structure is more or less destroyed, and its 
elementary parts converted into oily matter. 

Fibrous Degeneration is somewhat allied to Induration, and is probably 
connected with the existence of a fibrinous crasis. It occasions the 
gradual thickening of serous membranes and of areolar tissue by the 
formation of an imperfect kind of fibrous structure. This may attain a 
considerable thickness, and then by its dead white aspect resemble very 
much a layer of cartilage. The capsule of the spleen is sometimes thus 
altered, and has been wrongly said to have undergone cartilaginification, 
for there is no real similarity between this substance and cartilage. The 
white patches formed on the surface of the pericardium and in the capsule 
of the liver, are produced in this manner, and so is also that thickening 
of the Glissonian sheaths, which give rise, in many cases, to cirrhosis. 
The fibres are probably formed, in part, directly out of the effused blas- 
tema, in part, also, by nuclei, developing short fibres, which unite, as 
Henle has described. This latter mode of formation is often observed 
in the spleen. The chief difference between induration and fibrous de- 
generation consists in this, that in the former, a notable quantity of 
blastema is effused, which becomes the induration matter, and compresses 
and atrophies the adjacent texture; in the latter, there seems to be scarce 



TEXTURAL CHANGES. 165 

any perceptible exudation, as it takes place slowly, and passes at once 
into the condition of fibre. Induration may affect any tissue, while 
fibrous degeneration is chiefly seen in membranes. Cartilage, however, 
is liable to a fibrous transformation of a somewhat different kind, which 
will be hereafter noticed. 

The Calcareous degeneration rarely occurs as a primary change, it is 
almost always secondary to some other. Especially, it seems to be con- 
sequent upon a fatty degeneration of the arteries, to which the term 
atheroma is applied, and which may occur at any period of life, while 
the calcareous change is seldom observed very extensively except in 
advanced age. We have already alluded to the calcifying process, under 
the head of tubercle, as one of the metamorphoses which that deposit 
might undergo, and we shall find hereafter that it affects other formations 
also. It is often spoken of as ossification, and, indeed, not altogether 
without reason, as the "lacunas" characteristic of bone are found in this 
substance also; they are, however, irregularly and imperfectly developed. 
The earthy matters deposited are principally phosphate of lime and 
magnesia, and carbonate of lime; Rokitansky considers that they are 
not so much new deposits as precipitations from their natural combina- 
tions with animal matters. Calcareous deposition seems generally to 
take place in parts whose vitality has been considerably lowered by 
previous morbid processes within them. Thus it is common, in lymphatic 
glands which have been the seat of scrofulous disease, in obsolete croupo- 
fibrinous deposits, in the coats of arteries which have begun to be affected 
by atheroma, and in the valves of the heart under similar circumstances. 
The atheromatous condition, which we shall describe more particularly 
when we speak of the diseases of arteries, may either terminate in 
softening and breaking down of the arterial coats, or in calcareous 
deposition; both of these changes often coexist, but the latter predomi- 
nates in old age. We think, however, that deposition of earthy matter 
may take place to a great extent, so as to produce the ossification so 
common in the vessels of the aged, without previous atheromatous or 
fatty degeneration. The quantity of earthy matter in the bones becomes 
greatly increased in later life ; it is even deposited in the so-named per- 
manent cartilages, and it is, therefore, not surprising that it should 
also affect the walls of the vessels. This degeneration probably is oc- 
casioned solely by a failure of assimilative nutritive power in the tissue 
itself. 



CHAPTER IV. 

NEW FORMATIONS. 

It is difficult to give a perfectly exact definition of the class of new 
formations ; for we shall exclude from it many productions which are 
not found in the healthy organism, and shall include in it some which 
are but the result of the action of parts normally existing. Thus, we 
shall not mention the excessive production of fat-cells, which takes place 
in general obesity, as an instance of new formations, while we shall con- 
sider as such the distension of a sebaceous follicle into an encysted tumor. 
This defect, however, is common to all arrangements. Nature pre- 
sents us readily with distinct types of different classes ; but rarely, if ever, 
does she define and separate her groups by any exact limitation, and the 
rigid taxonomist wearies himself in the search for that which does not 
exist. The idea which is conveyed in the term " tumors," seems, in a 
general way, most descriptive of the class now before us, which may be 
said to include all new prominent or otherwise apparent local growths. 
The character of growing excludes tuberculous and other deposits, and 
concretions. We shall follow, in the main, the arrangement of the 
various kinds of new formations which Rokitansky has adopted, en- 
deavoring to set forth their distinctive features as far as possible, and 
yet recognizing the frequent insufficiency of any structural or chemi- 
cal peculiarities that we can observe — to explain, or even diagnose, the 
essentially different natures of different specimens we may meet with. 

(1.) Fibrous Tumors. — These constitute a group with tolerably well- 
marked structural characters, but shading, almost imperceptibly, into 
other species of very different nature. They are essentially made up of 
fibres, more or less closely resembling those of areolar tissue, but ap- 
pearing, in very various stages of development, in different specimens. 
Sometimes the fibres are tolerably distinct and separate; more often so 
interlaced and blended together, or so imperfectly evolved, that they 
cannot be made out as such. Sometimes the nuclei, with which the 
structure is loaded, seem to be simply imbedded in a granulo-homo- 
geneous blastema, the whole forming a dense solid mass; sometimes the 
blastema is divided into fibres, very similar to those of organic muscle; 
and sometimes, again, but more rarely, the blastema is broken up by 
fibrillation into bundles of filaments, identical with those of white fibrous 
tissue. Yellow elastic fibres are not unfrequently mingled with the white, 
and seem to be developed from the elongated nuclei. Much difference 
is observed in the chemical behavior of tumors of this class. Those 
which consist of fully developed fibres yield gelatin, while from those 



NEW FORMATIONS. 



167 



which consist of muscle-like fibre, or of an undivided blastema, none 
can be obtained. 1 



Fig. 48. 




Drawing of section of fibrous tumor. 



Fibrous tumors differ much in their degree of connection with sur- 
rounding parts ; sometimes they are quite blended with them by con- 
tinuity of tissue; at others, they are easily enucleated. They have 

Fig. 49. 




Fibre-fatty tumor. The upper figure shows fat-cells imbedded in fibrous tissue ; the left lower one 
represents a fat-cell capsulated by fibres; and the right some separate fibres. 

very few vessels indeed; so few, that it is matter of surprise how some 
large masses maintain their vitality. These tumors develop themselves 
in very different parts of the body, usually in such as normally contain 

1 This is Vogel's statement; but we have certainly obtained abundance of gelatin from 
umors consisting of undivided blastema. 



168 



NEW FOEMATIONS. 



much fibrous tissue. The uterus is one of their most common hdbitats, 
which probably depends on the similarity between the undeveloped mus- 
cular fibre of the organ and their own structure, so that a slight altera- 
tion in the conditions of nutrition might cause the common blastema to 
take the form of fibrous tumor, rather than of uterine fibre. Several 
fibrous tumors may exist in the same organ ; but it is rare that they co- 
exist in separate organs. They are not liable commonly to any great 
degree of change. Inflammation may occur, characterized by injection 
and softening of the part, and probably by the presence of exudation 
corpuscles in it. Cretification is not unfrequent, and may either com- 
mence indifferently at any part, proceeding until the whole is converted 



Fig. 50. 



Fig. 51. 





Fat-cells and granular matter, from a steatomatous 
tumor of the ovary .—Bennett. 



Structure of a fatty tumor removed from the 
hack. Lipome. a. Isolated cells showing the crys- 
talline nucleus of margaric acid. — Bennett. 



into a calcareous mass ; or it may be in great measure limited to the 
peripheral stratum, which it thus converts into a kind of shell, inclosing 
the rest. The calcareous degeneration affects tumors of very different 
size, and does not bear any relation to the age of the growth. Melanic 
matter is. sometimes deposited abundantly in fibrous tumors. Cyst-like 
cavities, filled with clear fluid, are occasionally found in fibrous tumors, 
constituting thus a fibro-cystic variety. Another results from their 
combination with adipose tissue, of which we have figured a specimen. 
The form which fibrous tumors assume is mostly the spherical, with a 
more or less nodulated exterior. If, however, they grow near a free 
surface, they are very prone to become pedunculated. It is probably 
from this tendency, together with subsequent wasting of the peduncle, 
that fibrous tumors are occasionally found free in the cavity of the uterus. 
In a case which came under our notice, there was no trace of peduncle. 
The tumor, of large size, had greatly distended the uterine cavity, and 
had very slight connection with the parietes. The size which fibrous 
tumors sometimes attain is very considerable, some have weighed as 
much as thirty-five or thirty-nine pounds. Between proper fibrous tu- 
mors and instances of mere hypertrophy of the integument, there exist, 
or may occur, every intermediate variety. In proportion as the texture 
of the formation becomes dense, it is more abundantly permeated by 
vessels, so that some of these growths are highly vascular. Of this 



NEW FORMATIONS, 



169 



kind is the rather rare Keloid tumor, a specimen of which we have lately 
had an opportunity to examine. It was situate on the back, was well 
defined, of a red color before removal, but pale after. It had much the 

Fig. 52. 




Fibrocystic tumor from back : (b) after addition of acetic acid. 



appearance of a thick red cicatrix, as if formed by a kind of transfor- 
mation of the skin itself. The structure, under the microscope, appeared 
as a dense woof of fibrous tissue, resulting from a pretty thoroughly 
fibrillated blastema. Acetic acid brought into view numerous nuclei, 
all more or less elongated, some quite passing into streaks, as if about 
to form nucleus fibres. A good deal of free, oily matter was diffused 
through the mass. Another specimen we have lately examined consisted 
of a fibrillating but undivided blastema, imbedding numerous nuclei, for 
the most part elongated and streaky. It involved the corium of the 
skin, but the epidermis passed evenly over it. It was very remarkable 
that the deeper layers of the epidermis consisted of vertically elongated 
cells and nuclei, while the upper layers were of the usually flattened 
shape. This probably depended on the abnormal fibrefying tendency 
having affected the cell growth on the free surface of the basement mem- 
brane. Tegumentary tumors, as they are termed by Mr. Simon, seem 
to be properly included in the class we are considering, as they consist 
essentially of an increased growth of fibrous structure. 

We may here allude to a group of tumors, for which Mr. Paget 
proposes the name of Recurring Fibroid. They are almost identical 
with common fibrous tumors, both in their naked-eye aspect, and in 
their microscopic characters, but show a remarkable tendency to return 
after removal. It is an extremely important and interesting circum- 
stance, that the later produced tumors approximate much more in 
appearance and in behavior to the malignant character, than the origi- 
nal one. In one of Mr. Paget's cases, the last production was hardly 
to be distinguished by the naked eye from encephaloid (and, indeed, we 
doubt if it was different), though it still consisted of the same elongated 
fibre-cells. The chief pathological interest of these tumors consists 



170 



NEW FOEMATIONS. 



in the circumstance that they form a kind of transition between the so- 
called innocent and the malignant formations. According to our belief, 
the circumstance of structural resemblance to fibrous tumors, is no 



hinderance whatever to the possession of malignancy, 
may have this fatal gift as well as any other kind. 



A caudate cell 



Epidermic and epithelial tumors constitute a well-marked class of 
new formations, which are of very frequent occurrence, and much prac- 
tical interest. Warts and callosities of the skin are minor instances of 
this group, and consist simply in thickening of the epidermis, produced 
by accumulated layers of its scales. As an increased flow of blood to 
the part must take place, it is not surprising that the papillae of the 
corium beneath should, in some of the more advanced cases, become 
hypertrophied and elongated, so as to project upwards into the little 
tumor. In condylomata, mucous tubercles, and similar vegetations, 
which are apt to form about the orifices of mucous canals, under the 
irritation of syphilitic and other discharges, the surface is commonly 
observed to be tabulated or papillar, the interior marked by a vertical 
striation, while some vascular ramifications extend up into each papilla. 
The structure of these is beautifully figured by M. Lebert. The sur- 
face of each papilla, as shown in his plates, is formed by a layer of 
closely imbricated epithelial scales ; while the deeper parts consist of 
either less flattened cells, or, according to our own observation, of nu- 
clei, lying close together in a granulous and amorphous blastema. This 
interior nucleated granulous tissue, we believe, is continued downward 
to the base of the growth, and encroaches on the corium of the skin ; 
for we have never been able to observe any clear demarcation between 
the vascular loops and the surrounding cell formation. Almost the 
very same description applies to those tumors which are most common 
on the lips, and whose cancerous nature one has often too much reason 

Fig. 53. 




(A) Papillary prominence of epithelial growth. 

(B) Epithelial tumour from lip. 

From Lebert. 



to suspect. These attain a much larger size, and are more manifestly 
vascular than the preceding, and their papillae are more branched and 
grouped together, so that the surface resembles somewhat that of a 



NEW FOKMATIONS. 171 

cauliflower. We believe it is not always possible to say, from the 
structural characters of these growths, whether or not they are malig- 
nant, or whether, if removed, they will return again. To this point we 
shall advert again, under the head of " Cancer." Horns are epidermic 
productions, which are occasionally formed upon the head, the fore- 
head, or some other part of the body. They originate in the sebaceous 
follicles, whose epithelium, thrown off in unnatural and excessive 
quantities, and mixed with the fatty secretion, forms a conical mass, 
which protrudes from the orifice in the skin, and is pushed onwards 
continually by fresh accretions to its base. M. Lebert quotes a case in 
which the horn was six to seven inches broad at its base, and six inches 
long. A contusion, or ulceration of the skin, preceded the appearance 
of the tumor. 

Melanotic tumors are not unfrequently spoken of by various authors, 
and occupy in their arrangements a place with other classes; but there 
is very great reason to doubt whether, properly speaking, any such 
thing ever exists. This is indeed generally admitted, and we now pro- 
ceed to show why it is so. Melanosis (meaning thereby the deposit of 
black pigment) is an extremely common occurrence, and may take place 
in healthy tissues, in those which are variously diseased, and in new 
formations of any kind. The pigment is in the 
form of minute granules, or sometimes of almost Fi S- 54 - 

dust-like molecules. It very commonly occurs ^ \x 

free, though the particles may be more or less 
closely massed together, but is very often also gj| % 

contained in the interior of cells. There is nothing <gk 1 

at all peculiar in these pigment-containing cells. ^| ^ 

Thev seem to be simply the natural cells of the " . , ... „ . 

J r ^ , . . . Melamc deposit in cells of an 

organ, or of the new growth in which the deposit engorged lung, some of the 
has occurred. Pigment granules are seen in the ceiis contain oil-drops, 
same part, both free and contained in cells, so 

that it is clear that their presence in the cells is of no special import. 
Rokitansky gives the following enumeration of localities, in which the 
melanotic deposit takes place: In the lungs, both in the air-cells (often 
in their epithelial particles), and in the connecting areolar tissue. When 
contained in the air-cavities, it is in all probability chiefly inhaled as 
carbonaceous matter, floating in the air. We examined some time ago 
the lungs of a man who had been a worker in a gunpowder manufactory, 
and found them to contain a very remarkable quantity of free black 
matter. In the bronchial glands, its quantity in them being usually in 
proportion to that in the lungs, it is rarely contained in cells. In the 
mucous membrane of the stomach and intestines, of the uterus, and oc- 
casionally of the air-passages, it is generally the result of the irritation 
of chronic catarrh, and is derived from altered hsematin. In the 
mesenteric glands, coexisting with such deposits in the mucous tissue, 
it produces a slaty gray, or still darker discoloration, spotted or uniformly 
diffused. In the sympathetic ganglia. In the skin, either naturally, 
in the dark races, or as the local discolorations, termed "melasma." 
In new formations, as intravascular coagula, atheromatous patches, and 
their cicatrices, in hemorrhagic masses, false membranes of inflammatory 



172 NEW FOKMATIONS. 

origin, tubercle, especially the hemorrhagic variety, colloid matter, and 
cancerous growths. Lastly, melanotic matter occurs in fluid exudations, 
and in the cavities of cysts. Rokitansky is of opinion, that the deriva- 
tion of the black pigment from the coloring matter of the blood is a 
settled point. We are rather inclined to agree with him than with Dr. 
Walshe, who thinks "that the relation of true melanic cell-pigment to 
the constituents of the blood, is altogether unknown." It is quite certain 
that, in all the instances above mentioned, except that of the air-cavities 
of the lungs, the melanic matter proceeds in some way from the blood ; 
but the question is, how? Is there first extravasation of the blood, ex- 
udation of its hsematin, and conversion of this into the pigment; or is 
this produced from the liquor sanguinis, in some unknown way of secre- 
tion ? We are inclined to think the latter is not unfrequently the case, 
and for the following reasons: (1.) It seems quite impossible to believe 
that the very considerable quantity of black matter, often found in the 
interlobular tissue of the lungs of old persons, should have proceeded 
from local congestions and extravasations, especially when there is no 
trace of previous inflammatory action. (2.) We are well acquainted 
with the changes which haematin does undergo in the splenic tissue and 
in the renal tubules, when blood has escaped out of the vessels; and we 
have far most commonly observed the color of the granules to be an 
orange or reddish yellow. The same is the case in the remarkable pro- 
duction of yellow matter, which takes place in the congested centres of 
the hepatic lobules. (3.) We have observed, particularly in the embryo 
of the fish, the development of pigment, and seen it commence by the 
appearance of a minute free particle of intense blackness, smaller than 
a nucleus, close by the side of a vessel; so also, in the abundant formation 
of black pigment which takes place in the liver of the frog at certain 
times, there is not the least reason for regarding it as specially derived 
from the red coloring matter of the globules, but much more for supposing 
it to proceed from some of the highly carbonized matters contained in 
the liquor sanguinis. In this instance, as in many others, truth lies 
intermediate between opposite opinions. The chemical composition of 
melanotic matter is not accurately ascertained, and probably hardly can 
be, owing to the difficulty of obtaining it at all pure, and perhaps also 
from variations in the composition of different specimens. It is clearly, 
however, a very highly carbonaceous substance — indeed, that obtained 
from the lungs of aged persons, by M. Guillot, seems to have been actually 
carbon. Dr. Walshe mentions that a specimen of softened melanotic 
tumor, which he examined, was not deprived of its color by acids or 
alkalies, only by chlorine. Strong nitric acid, however, with the aid of 
heat, turned it yellow. From the foregoing account of melanosis, it will 
readily appear that, from the very commonness of its occurrence, it is 
impossible to regard it as giving a really distinctive character to a tumor. 
The growth is essentially something else — a cancerous, or sarcomatous, 
or some other formation, and the melanotic tinging is accidental. 

Fatty tumors, or Lipomata, as they are sometimes termed, are of fre- 
quent occurrence. They consist of normal fat-cells, closely packed 
together, and invested by a rather sparing quantity of common areolar 



NEW FORMATIONS. 173 

tissue. Occasionally, this investment is more developed, and constitutes 
a kind of enveloping cyst; occasionally, also, it dips down, and forms a 
cystoid covering to separate portions of the tumor. They occur most 

Fig. 55. 




Adipose tissue from a fatty tumor. 

often singly, but not unfrequently several exist together in the subcu- 
taneous tissue. They attain, occasionally, an enormous size, so that 
records speak of specimens several feet in diameter, and weighing 20 — 
40 pounds. Their most common seat is the subcutaneous areolar tissue, 
especially in regions where fat is apt to collect, as on the buttocks, the 
thighs, the back and neck, &e. They have, however, been seen in many 
other parts, as beneath the scalp, in the submucous tissue of the stomach, 
intestines, bronchi, and in the underlying areolar tissue of the various 
serous and synovial membranes. In the knee-joint, especially, fatty 
growths have been distinguished by Muller as " lipomata arborescentia,'" 
in consequence of their branching form ; this seems to result from their 
originating in the areolar tissue, and growing inward towards the syno- 
vial cavity. Lipomata have further been observed in the lungs, liver, 
and kidneys, and in the bones. The surface of lipomata is commonly 
lobulated — their form, for the most part, globular ; they have a peculiar 
doughy feel, with some degree of elasticity. They grow slowly, and 
occasion inconveniences only by the pressure they exert on surrounding 
parts ; when at last this distension becomes excessive, the skin covering 
the tumor attenuates, and ulcerates, and a sloughing sore may be thus 
produced, which may destroy life by exhaustion. It sometimes happens 
that a fatty tumor seated in the submucous tissue pushes as it grows the 
yielding membrane before it, and thus, acquiring a pedicle, hangs into 
the intestinal cavity. A steatoma, according to Rokitansky, is a fatty 
tumor, with a preponderating excess of areolar tissue, and hence of firmer 
consistence. Lebert applies the name to collected masses of fatty matter, 
not consisting of fat-cells, but of concrete fatty granules. Dr. Walshe 
says, that the steatoma is close in grain, inelastic, opaque, suet or putty- 



174 NEW FORMATIONS. 

like, composed of granular, amorphous, and non-vesicular fat. To this 
kind of tumor we think the name most suited. 

Another variety of fatty tumor is the cholesteatoma, in which a sub- 
stance allied to cholesterin is secreted in the interior of a fibroid cyst, 
lined internally by a delicate epithelium, which is probably the secreting 
organ. The contents are of a glistening mother-of-pearl aspect, though 
sometimes of a dull white ; they are arranged in delicate concentric 
laminae. The laminae consist of superimposed strata of cells, rendered 
polygonal by mutual pressure, and resembling, except in size (being one- 
half smaller), the cells of sheep's-fat. Between the laminae there are 
numerous crystals, which are of tabular and lamellar shape, and seem to 
consist of pure cholesterin. A similar matter is occasionally found on 
the free surface of cancerous and other ulcers. 

Before we proceed to describe vascular tumors, which constitute our 
next class, we shall give some account of the development of new vessels 
in inflammatory exudations, and other blastemata. Two opinions are 
held at present as to the mode in which their formation takes place. 
By some, as Paget, Travers, and Simon, they are considered to be 
formed by "outgrowth from adjacent vessels." Small dilatations appear 
on the side of a vessel, increase in length 4 , and at last meet and coalesce 
with similar diverticula in their vicinity ; in this way a new capillary 
loop is formed, and the process is carried on in the same way. On the 
other hand, Rokitansky, Vogel, and Dr. Walshe agree in regarding the 
new vessels as originating spontaneously in the exuded blastema. We 
strongly incline to the belief that their view is the correct one,* or at 
least that bloodvessels are formed in the latter as well as in the former 
manner. The following description is taken from Rokitansky and Vogel : 
In the substance of the exuded material there appears to the naked eye 
small roundish spots full of blood, from which there proceed in all direc- 
tions minute streamlets filled with the same red contents. These primary 
channels are at first mere excavations in the blastema, and have no 
lining membrane; after a time they present the characteristic homoge- 
neous coat of true vessels, and at a later period the external tunics are 
added. The blood-globules originating within their channels are more 
irregular in size, less exactly shaped, and have not the deep red color 
of the original ones. It seems certain that the primary blood-containing 
spaces and their offsets are not ramifying cells, for they appear in the 
blastema before the formation of cells, or even of fibroid tissue ; the 
development of blood at certain points seems to be the only determining 
cause of their formation, just as it is in the embryo. Our knowledge 
respecting the influence which the nature of the blastema has on the 
production of new vessels, amounts to this — (1), that in blastemata under- 
going similar developmental changes, the tendency to the formation of 
vessels is much greater in some than it is in others; (2), that in blaste- 
mata which remain in their original crude solid state, and do not break 
up by fibrillation, very little vascular development takes place. The 
vessels originating as just described, are larger than capillaries, at least 
in parts of their courses, less uniform in caliber, and more delicate ; 
they communicate with the general circulation by extending through the 



NEW FORMATIONS. 175 

blastema till they meet with the vessels of the subjacent membrane, and 
anastomose with them. Another variety in the mode of development 
of new vessels has been observed by Rokitansky in cancerous blastemata. 
Parent-cells, such as might have contained a brood of young cells, were 
seen filled with red blood-globules ; offsets proceeded from these cells 
filled with the same red contents, and formed anastomoses with similar 
ones from adjacent cells. The same special tendency to vascular deve- 
lopment is evidently inherent in some cancerous and non-inflammatory 
blastemata as in the common ; thus, encephaloid growths are sometimes 
so highly vascular as to be considered a distinct variety, the Fungus 
Haematodes; in multilocular ovarian tumors, some loculi will be found, 
whose contents are red with blood, while in adjacent ones scarce any 
trace is visible. To say why vascular formation should so remarkably 
predominate in one growth, or part of a growth, rather than another, is 
as difficult as it would be to explain why one organ, or one part of an 
organ, is naturally more vascular than another; for instance, why muscle 
is more vascular than tendon. 

From these remarks upon the excessive development of vessels, we 
naturally pass to the consideration of growths which mainly consist of 
them, and are consequently called vascular tumors. Of these there' 
seem to be two kinds, one consisting of dilated, arterial, or venous 
branches, with a certain quantity of interposed areolar tissue, to which 
the name angeiectoma may properly be applied ; the other presenting 
a more truly erectile texture, i. e. spaces separated by intervening 
columns of fibrous tissue, and lined by an epithelium, which are dis- 
tended by blood in a greater or less degree. The communication be- 
tween the cells and the arteries is more or less free ; when the former 
is the case, the tumor pulsates strongly. Naevi are tumors of this 
kind, occurring in the skin, which is their most frequent seat ; they also 
occur, however, in numerous other parts, even in the interior of bones, 
which become dilated and thinned by their growth. They are very 
often congenital, their increase in size sometimes is very rapid, and 
seems to be favored by a contusion, or any cause of irritation. Of the 
non-malignant character of erectile vascular tumors there can be no 
doubt ; they contain nothing but a fibrous structure interposed between 
their vessels; but with regard to some other growths, more of the 
character of the angeiectomata, there may often be room for doubt, at 
least during life. Microscopical examination, however, of the tumor, 
will in most cases readily show whether any elements which can be 
considered as cancerous are mingled with the dilated vessels. A simple 
vascular tumor, though it may accidentally burst, and give rise to 
hemorrhage, does not soften, and ulcerate, and bleed in the same con- 
tinuous way that an hsematoid cancer does. Little is positively known 
as to the way in which vascular tumors are formed ; the angeiectoma, 
consisting as it does of dilated vessels, must in some way proceed from 
a defective contractility of the vascular coats, which yield to the dis- 
tending impulse of the heart. This defect seems in some cases, as in 
those quoted by Dr. Carswell, to pervade the arterial system through- 
out, or at least in a considerable extent, instead of being localized in 
one part (v. fig. 3, plate iv. in his work), where the common iliac arte- 



176 



NEW FORMATIONS. 



ries and their divisions are strangely contorted and expanded into 
pouches and dilatations. Erectile formations must acknowledge some 
other cause more deeply affecting the original formative process, but 
we do not think with Rokitansky that their cells originate as excava- 
tions in a solid blastema. The rapidity with which, when imperfectly 
removed, they often return again, also indicates a special modification 
of the laws which determine the formation of tissue. 



Enchondroma. — This name was applied by Miiller to certain tumors 

Fig. 56. 




Enchondroma ; microscopic structure — after Lebert. 



essentially consisting of cartilaginous structure, whose real nature was 
first discovered by him. They must be carefully distinguished from all 



Fig. 57. 




Fig. 58. 

f i m 

- 



Fig. 59. 




mm 



Fig. 57. Thin section of the circumference of an enchondroma from the pelvis. 
Fig. 58. Corpuscles from the softened part of the same tumor. 
Fig. 59. The same, after the addition of acetic acid. — Bennett. 

those dense white fibrous thickenings which present very much the ex- 
ternal aspect of a layer of cartilage. Enchondroma forms usually a 



MYELOID TUMORS. 177 

globular tumor, -with a smooth or somewhat tuberiform surface. Inter- 
nally, a section displays a number of loculi of very irregular roundish 
shape, filled with a firmly gelatinous, or rather pellucid substance. The 
walls of the loculi consist of a whitish fibrous tissue, more or less closely 
resembling that of fibro-cartilage ; in some much rarer cases, this is re- 
placed by an amorphous, firm, intercellular substance, very similar to 
that of true cartilage. The gelatinous matter consists of roundish or 
elliptic cells, varying from i^^th — g Jo* n ^ nca m diameter, containing 
granular nuclei, or secondary nucleated cells in their interior. Enchon- 
droma, by boiling, generally yield chondrin, the same substance as is 
obtained from ordinary unossified cartilage ; occasionally, however, it 
yields glutin. Tumors of this kind sometimes originate in the interior 
of the bones, which they expand so as to form a thin capsule covering 
their surface ; this is sometimes absent entirely, or may be deficient at 
certain spots. In the interior of the mass there often remain inclosed 
portions of the cancellous tissue of the bone. Vogel states that enchon- 
dromata may originate also on the surface of bones, especially the flat ; 
in this case they are of course invested only by periosteum, and not by 
any bony capsule. Enchondroma is occasionally observed in soft parts; 
it contains then no bone, and its structure is more purely that of hyaline 
cartilage. The chosen seat of enchondroma is in the bones, especially 
in the phalanges of the toes and fingers ; out of thirty-six cases the 
metocarpus and phalanges were affected twenty-six times, the tibia 
three, the ilium one, the cranium one, the ribs one. In the four other 
cases, the testicle was in two the seat of the disease, the parotid in one, 
the mamma of a dog in one. Rokitansky mentions having seen it also 
in the subcutaneous cellular tissue, and in the bony. It occurs most 
often in the young, but sometimes has not appeared until an advanced 
period of life ; when this is the case it is often associated with exostoses 
and osteophytes. Enchondroma is of slow growth, and does not usually 
attain a large size ; one instance, however, is recorded, in which the 
tumor weighed nine pounds and a half. They do not contaminate the 
system, and only become dangerous if they inflame and ulcerate, and 
pour out a copious discharge. Cartilaginous tumors are prone to ossify, 
and in this instance the term is not misapplied, as true bony structure 
is really found. The ossific change sometimes seems to have com- 
menced at the root of the tumor, at its bony attachment, and to extend 
outwards towards the circumference, following the progress of the car- 
tilage formation, just as it does during the growth of the shaft of a long 
bone. In this way a cartilaginous tumor is converted into an exostosis. 
In other cases ossification commences from numerous independent cen- 
tres, from which bony fibres radiate in all directions, and would, after 
a time, become confluent. 



MYELOID TUMORS. 

In his eighth lecture, Mr. Paget has described, with his usual ability, 
a class of tumors with which pathologists have but recently become ac- 
quainted. They are termed myeloid, from their being usually deve- 
12 



178 OSSEOUS TUMOES. 

loped in or upon bones, and from the similarity of their structural 
elements to certain corpuscles found in the marrow (pv£%ov) of young 
hones. The tumor may either be inclosed in a capsule of expanded bone, 

Fig. 60. 




Kemarkable example of ossification of enchondromatous tumor. 

or only by a periosteal investment. They are, for the most part, rather 
firm, but brittle, compact, of spherical or ovoid shape when invested by 
bone, more irregular and lobulated when growing upon bone. The cut 
surface is smooth, uniform, shining, succulent, with a yellowish fluid ; 
commonly variegated by blotches of dark or livid crimson, or various 
shades of red upon a greenish or grayish white ground. The structural 
elements characteristic of myeloid tumors are large, round, oval, or 
irregular cells, and cell-like masses, of clear, or dimly granular sub- 
stance, g^Q — toVo m °h diam. ; and containing from two to ten or more 
oval, clear, and nucleolated nuclei. With these occur caudate and fibre- 
cells, and free nuclei, and the whole are imbedded in a dimly granular 
substance, mingled with more or less of molecular fatty matter. The 
history of these tumors, as far as is known, is nearly as follows : They 
usually occur singly, are most frequent in youth, and very rare after 
middle age ; they are of slow growth, cause no pain, have no tendency 
to ulcerate, and are not apt to recur after complete removal. To the 
naked eye they may closely resemble malignant growths, but they have 
not any of their essential characters. For further details and illustra- 
tive cases, we refer to Mr. Paget's work, p. 212, from whence the above 
summary has been taken. 



OSSEOUS TUMORS. 

These may be divided into exostoses, osteophytes, and osteoid tumors. 
Before proceeding to describe them, we shall mention some of the vari- 
ous parts and tissues which have been observed to be the seat of true 
osseous formation. Articular cartilages rarely, if ever; the laryngeal 
and costal very frequently, especially in advanced age, and under the 
irritation of adjacent tuberculous ulcers, undergo ossification. The an- 



OSSEOUS TUMORS. 



179 



terior vertebral ligament occasionally ossifies, so do the tendons, fasciae, 
and aponeuroses in various parts. Dr. Walshe enumerates the follow- 
ing instances of the formation of bone in areolar tissue, in the sub- 
mucous tissue of the gall-bladder, in the sub-serous of the pleura, the 
sub-retinal, the intramuscular, the parenchymatous of the liver. He 
mentions also ossification of muscular fibre and of the crystalline lens 
as having occurred. 

An exostosis is an osseous tumor, proceeding from the bone or its 
periosteum, and, according to Rokitansky, homologous in texture, when 
fully developed, with that of its base and point of origin, whether 
that be compact or spongy. Its form varies — being sometimes broad 
and flat, sometimes round and prominent, with a narrow neck, some- 



Fig. 61. 



Fig. 62. 




Fig. 61. Remarkable osseous tumor of os innominatum. Fig. 62. Back view of same preparation. 

Front view. 

times spinous. They do not often attain a size above that of a hen's 
egg. Sometimes they are single; but often several exist together in the 
same individual, and even on the same bone. In texture, they vary 
considerably from that extreme degree of density which constitutes the 
"ivory exostosis" to the porosity of ordinary cancellous tissue. The 
compact exostosis "is compact from the very first, and grows in such 
a way that the layers which are added to it always at once become 



180 OSSEOUS TUMORS. 

as dense as ivory." "When they are minutely examined, the num- 
ber of peripheral laminae is found to be very considerable, and the 
corpuscles lying amongst them are long. The Haversian canals are 
small and far apart," and the corpuscles in some parts are quite absent, 
in others are closely crowded together. "The spongy exostosis pro- 
ceeds from a circumscribed rarefaction or expansion of the bony tissue. 
It forms a tumor of cellular texture, abounding with marrow, which is 
surrounded by a compact layer or rind." It may originate from the 
compact outer layer of the bone, or from its spongy interior. In some 
cases a tumor of this kind contains in its interior a well-formed me- 
dullary cavity, communicating with that of the bone. The spongy 
exostosis may remain in the same condition, or become indurated and 
more similar to the compact, by the deposition of more earthy sub- 
stance. If, as occasionally happens, a bony tumor grows inward into 
the medullary canal of a bone, it is termed an Enostosis. Exostoses 
often arise without any obvious cause ; sometimes they appear to develop 
in consequence of a blow or strain. "In most cases the periosteum 
covering them is in its natural condition;" sometimes it is thickened 
and unusually adherent. They are not peculiar to any period of life ; 
those of the spongy kind have been observed even in new-born infants. 
Spongy exostoses are sometimes destroyed by caries; and in a few cases 
the ivory exostosis has become necrosed, and been thrown off. This 
change must proceed, no doubt, from obliteration of the Haversian 
canals, and consequent cessation of its nutrition, and would be similar 
to the shedding of the antlers of the stag. 

Osteophytes. — To this class belong a great variety of bony growths, 
which form, for the most part, in inflammatory exudation, are pretty 
widely spread, in many cases, over a bone, and are rather easily separa- 
ble from it. In these respects, and in their greater irregularity, they 
differ from exostoses, which are to be regarded as outgrowths from a 
bone, while osteophytes seem only to be produced under the influence of 
a bone. Osteophytes, of warty or stalactitic shape, are very common 
in the neighborhood of diseased joints, where the articular surfaces are 
affected with caries. They result, doubtless, from ossification of the ex- 
udation, derived from the adjacent hyperaemic vessels. In front of the 
vertebral joints and some other synchondroses, pretty long styloid or 
lamellar osteophytes frequently are produced, so as even sometimes to 
form a kind of bony capsule around them. " They arise from a chronic 
inflammation of the bones," and while these are atrophied, are often of 
dense hard texture. Sometimes the osteophyte is said to be foliaceous, 
consisting of beautiful delicate lamellae, arranged parallel to each other, 
and running transversely vertical to the axis of the bone. The flat 
osteophyte is sometimes an extremely thin and delicate layer (like hoar 
frost) ; sometimes it is one or two lines in thickness. It is composed of 
delicate fibrils and lamellae, and at first has scarce any attachment to 
the bone upon which it lies. "At a later period the osteophyte is found 
attached to the bone by some intervening minute round pillars and plates. 
After having become gradually compact, it unites with the bone." To 
this variety belongs the puerperal osteophyte, to which attention has 
of late been particularly directed. An account of this will be given in 
the chapter on the osseous system. 



CYSTOID TUMORS. 181 

Osteoid tumors, in Rokitansky's opinion, are simply cancers, in which 
the stroma has undergone true ossification. This view is favored by 
the fact, that similar tumors are very apt to develop themselves in 
other and internal parts, whether the original growth has been removed 
or not. Lebert, however, distinguishes them from cancer, and, from 
the accounts which are given of their structure, not without reason. 
They are described as tumors of irregularly protuberant surface, some- 
times of rapid, sometimes of slow growth, occasionally attaining a very 
considerable magnitude, and originating (the primary ones) from some 
bone. In structure, they consist of a cancellous bony tissue, which is 
plunged amid a grayish white, vascular, fibrous material, in which a 
sparing quantity of cells and nuclei are discernible. This substance 
seems to be similar to the ossifying basis of the cancellous tissue, and 
yields, on boiling, neither gelatin nor chondrin. The bony skeleton 
of an osteoid tumor may predominate more or less, so that the struc- 
ture may be like compact or spongy tissue. Varieties in this respect 
may be observed among the different tumors in the same individual. 
Osteoid tumors have been found in the cellular tissues, the serous mem- 
branes, the lungs, the lymphatic glands, and in the interior of the great 
vessels. From these and other facts, Lebert arrives at the rather vague 
conclusion, that the cause of the appearance of these tumors is a 
general osteoplastic diathesis. This does not advance our knowledge 
much, and, besides, we doubt whether it touches the principal point, 
which is, to know whether the tumor is essentially a bony tumor, the 
fibrous part serving only as an ossifying basis, or whether the bony 
formation, though constant, is secondary and inferior in importance to 
that of the soft matter ? Further observations must determine this. 
We may mention, that the name osteosarcoma is given to encephaloid 
tumors, originating from bone, and receiving into their mass long thorn- 
like or stalactitic or radiated offshoots of bone, from the natural tissue 
in the vicinity. These, in some cases, may resemble very much the 
arrangement of the bony portion of osteoid. 



CYSTOID TUMORS. 

These constitute a very large and important class of new formations. 
They agree in the one general character, that they form receptacles 
which are filled with various contents, but in other respects they pre- 
sent very great diversity. We shall separate them at the outset into 
two divisions, the one comprising cysts, which result from the distension 
of a natural pre-existing cavity, the other those which are entirely new 
formations. Under the first head we notice : (1.) The common so- 
called encysted tumors, which occur so often on the scalp and elsewhere. 
These are essentially sebaceous follicles, whose orifice has become ob- 
literated, and the cavity in consequence, distended by continually accu- 
mulating secretion. The contents of these cysts are of very different 
appearance, and the names of meliceris, hygroma, atheroma, gummy 
tumor, have been given to express a honey-like, watery, pultaceous, or 
jelly-like condition of the retained secretion. Examined microscopi- 



182 CYSTOID TUMORS. 

cally, epithelial scales, free fatty matter, tablets of cholesterin, crys- 
tals of triple phosphate, and small hairs in various proportions, the 
epithelium, however, usually predominating, are found to constitute the 
contents of these cysts. The cyst itself appears as a thin fibrous layer, 
lined on its inner side with epithelium. We have seen one case in 
which the epithelium in several tumors had accumulated in a very thick 
layer on the interior of the true cyst, giving rise to the appearance of 
a thick-walled cavity with contained matters of the ordinary kind; 
microscopic examination, however, showed that there was no real thick- 
ening of the cyst itself. The scaly particles of epithelium seem to fill 
themselves occasionally with a pellucid refracting matter, apparently of 
oily nature ; they are mingled in some cases with granular globules, not 
unlike pus-corpuscles, or if inflammation has occurred, with pus itself. 
This, at least, is the case with comedones, which are of a similar na- 
ture. (2.) Mucous encysted tumors; these are essentially similar to 
the preceding, and are formed by obstruction of the duct of a mucous 
follicle, or small conglomerate gland. They contain usually a glutinous 
mucous fluid. They occur in the lips, the mouth, in the cervix uteri, 
the Meibomian glands, and in the vagina. 1 Ranula is an exactly 
analogous affection of the duct of the sublingual gland. (3.) Some of 
the renal, and mammary, and probably most of the hepatic cysts are 
produced in the same way, by local obliteration of the duct canals at 
two points, and distension of the intermediate portion. (4.) Single 
cysts in the ovary are perhaps formed by dropsical distension of the 
Graafian vesicles; this may also be the origin of others which are 
afterwards compound. (5.) Cysts in the thyroid gland are, no doubt, 
often formed by simple expansion of the normal vesicles. (6.) Certain 
bursse (not of new formation) become distended by a persistent increase 
of their secretion, and constitute cystic tumors. Mr. Simon states that 
the contents of these, instead of being fluid, are occasionally solid, the 
albuminous secretion having been replaced by a fibre forming (probably 
fibrinous) blastema. 

Under the second head, we notice: (1.) Simple serous cysts, and 
synovial bursse. These arise in some cases evidently from the effect of 
pressure or friction, in others without any such cause. In the former 
case, we observe that a kind of condensation takes place in the areolar 
tissue of the part, making out the limits of the commencing bursa; 
within this the fibrous bands are gradually absorbed, while a secretion 
at the same time of fluid takes place, and at last the cavity is lined by 
a more or less perfect epithelium, and the new formation is complete. 
We can discern the purpose for which such cysts are formed, the end 
they serve, but we have no idea of the nature of the action which de- 
termines their formation. With regard to the others, which form in 
situations removed from pressure, as in the broad ligament of the ovary, 
the cause of their production is utterly unknown. They consist of a 
wall of fibrous tissue, varying in thickness in some measure, according 

1 We found the contents of an encysted tumor of the eyelid, operated on hy Mr. White 
Cooper, to consist of a colorless, translucent matter, made up of multitudes of delicate 
granulous globules, imbedded in a clear fluid, which was coagulated in some measure by 
acetic acid. 



CYSTOID TUMORS. 183 

to the size of the cyst, condensed so as to form a smooth surface in- 
ternally, and lined by a thin layer of epithelium, which has generally 
appeared to us to consist of nuclear particles, with imbedding granulous 
matter, and not of perfect cells. The import of this condition of epi- 
thelium appears to have reference to the rapid secretory action which 
takes place. The fluid contents of these cysts may be poor or rich in 
albumen, may contain abundance of cell forms, or very few, and may 
be either loaded with cholesterin, or devoid of it. We can confirm the 

Fig. 63. 

O@ 00@©©©@)©O6>© 



^%^J^ 



Simple serous cyst, and epithelial particles from its interior — from vicinity of ovaries. 

statements of Mr. Simon, that the granule-cells, which are sometimes 
very numerous, are the seat of the color of the dark coffee-ground-like 
matter which is sometimes present in large quantity. Some of these 
simple cysts contain quantities of fat, hair, teeth, and even bone, so 
that some good authorities have expressed their belief that they were 
the remains of a partially absorbed foetus. This is certainly not the 
case, but their occurrence is of extreme interest, and being peculiar to 
ovarian growth, suggests very strongly that the normal reproductive 
function of this organ exerts itself by the development of these pro- 
ductions within its germ-bearing cavities, under the influence of some 
unnatural stimulus. This, of course, applies especially to the cysts 
alluded to under /the first head, as developed from the Graafian vesicles; 
but it is Rokitansky's opinion, that cysts of new formation may develop 
like products also. Mr. Paget states, that in these cases the wall of 
the cyst acquires in some part the character of true skin, with hair 
follicles, sebaceous, and sometimes perspiratory glands; and infers that 
" the structures and secretions formed on this portion of the cyst are 
shed into its cavity, and there accumulate; and that they remain, when, 
as often happens, the cutaneous structure on which they are produced 
has degenerated and disappeared." Several simple cysts may exist 
together in the ovary ; this, we should consider most likely to occur 
when they result from development of the Graafian follicles. Simple 
cysts not unfrequently occur in the mammary gland, or rather in the 
dense areolar tissue investing it ; they have a wall of condensed fibrous 
tissue, and according to Mr. Birkett, are lined by a characteristic epi- 
thelium, consisting of hexagonal particles. Their contents are either 
limpid, opalescent, non-albuminous fluid, or a tenacious, slimy, opaque, 
variously colored, and concentrated solution of albumen. "VYhen com- 
bined with a peculiar growth of gland tissue advancing into their cavity, 
these tumors constitute the sero-cystic sarcoma, of which we shall 
speak more particularly when we come to the morbid anatomy of the 
mammary gland. Cystic formation may take place in various kinds of 
tumors, in fibrous, carcinomatous, sarcomatous, and may be a more or 
less prominent phenomenon. (2.) Compound cysts. The chief seat of 



184 CYSTOID TUMORS. 

these is in the ovaries, where they present two principal modes of de- 
velopment. In one of these the parent cyst, which, for the most part, 

Fig. 64. 





Diagram of compound cysts. In the left figure, the secondary cysts are seen growing on the inner surface 
of the parent. In the right, they have filled up the cavity. 

continues to predominate in size, gives origin to a second generation of 
cysts, and then again to a third, and so on. The consecutive series of 
cysts are developed in the walls of their parents, but do not grow in- 
ward and occupy their cavities ; the result is a multilocular mass, made 
up of numberless cysts, which are filled with very various contents. 
These may be tolerably limpid and clear, or very viscous and greenish ; 
may contain a very large number of celloid particles, or very few ; may 
be variously colored by blood- globules of new formation, or even re- 
placed by a solid blastema loaded with developing blood ; fat, hair, 
teeth, and bone may also occur in these, as well as in the simple cysts. 
The partitions between the various cysts sometimes give way, and thus 
a tumor is produced, which internally seems imperfectly divided into 
compartments. In the other mode of development, the secondary cysts 
grow inward into the cavity of the parent, which they fill up more or 
less completely, a tertiary race behaves toward them in the same way, 
and so on. This form may be combined with the preceding. Roki- 
tansky describes a kind of villous, or cauliflower growth, which origi- 
nates on the wall of the secondary or parent cyst, and may increase 
so as not only to fill the cyst cavity, but to break through its wall, and 
vegetate in the cavity of the peritoneum. 1 The impression left on the 
mind of the observer after a minute examination of the compound cysts, 
is, that they are of the lowest type of organization, resulting, appa- 
rently, from a depraved, degenerate formative action, which, withdraw- 
ing blastema from its proper uses in the system, hurries it with a waste- 
ful expenditure into useless and injurious elementary shapes. How 
precious is the stringency of the law of our organic constitution, which 
is comparatively seldom infringed by such terrible aberrations ! It may 
be remarked, that the tendency to cyst formation most often appears 
in the existence of several together ; it is certainly far more common to 
find several, whether of new formation, or resulting from distension of 
natural cavities, than to find a solitary one. This indicates some spe- 
cial modification of the normal organic action; but we cannot think it is 
such as Rokitansky points out, when he ascribes all cyst formation, ex- 

1 In the Report of the Pathol. Society for 1851-52, there is an account, at p. 404, of a 
growth on the interior of an ovarian cyst which seems to be of this kind. It consisted of 
"vast numbers of pedunculated, clavate, clustered growths, formed apparently of a sim- 
ple basement membrane inclosing cells." 



CYSTOID TUMORS. 185 

cept that arising from mere distension, to the extraordinary develop- 
ment of a primary cell. 

Sarcomatous tumors constitute a group, which, it must be allowed, is 
very ill defined. We may describe what we regard as the characters of 
a typical specimen ; but we shall seldom find them all present in any 
given instance; and, frequently, they will approximate so closely to those 
of other classes, that we shall remain in some degree of doubt. The 
fibrous group on the one hand, and the carcinomatous on the other, are 
the territories which border on the debatable land of sarcoma. The 
characters attributed to sarcoma are the following: It occurs as a local, 
for the most part solitary formation, not affecting the constitution. If 
removed completely, it does not return. In shape it is well defined, 
roundish, with uneven or lobulated surface, often also branching and 

Fig. 65. 




Pancreatoid sarcomatous tumor. 
Fig. 66. 






Structural elements of same. 



extending itself between the adjacent tissues. Its size varies from that 
of a hazel-nut to that of a cocoa-nut (Walshe), or perhaps may be still 
greater. It seems to have no particularly determined site ; both 
maxillae (especially the upper), the interior of bones, glands, muscles, 
fibrous membranes, submucous areolar tissue, even the brain, are all 
mentioned as being affected by it. It belongs to an earlier period of 
life than carcinoma. Softening and breaking down do not necessarily 
occur in the progress of sarcomata ; but if they are exposed, by sloughing 
of the parts which cover them, they may inflame and saniate, or slough. 
The commonest variety of sarcoma is that which Rokitansky calls the 
albuminous fibrous tumor, on account of its yielding, on boiling, no 
gelatin, but an albuminous matter. The fibres are of various kinds, 
scarcely different from those of ordinary fibrous tumor. They lie in a 
diffused albuminous blastema, and are interwoven with a more or less 
abundant vascular plexus. Another variety is the gelatinous sarcoma, 
the same which Muller has named " collonema." It is sometimes very 



186 CYSTOID TUMORS. 

soft, clear, tremulous, like jelly, scantily supplied with vessels. In 
structure it presents, in different specimens, varying proportions of 
fibres, white or elastic, of celloid particles, elementary granules, and 
fibrillating blastema. In other instances the structure is more firm and 
resistent, of lobulated aspect, consisting of white filamentous tissue, 
intermingled with caudate nuclei and cells. In others, again, the inter- 
cell substance is firmer, more stiff and amorphous, so that the structure 
approaches that of enchondroma. Some sarcomatous tumors present a 
not very distant resemblance to the conglomerate gland structure, their 
mass dividing into lobes and lobules. To such, the name of pancreatic 
sarcoma has probably been applied. It is, however, pretty certain, 
that the same kind of structural arrangement exists in some cancerous 
growths. M. Lebert has examined sarcomatous tumors very carefully, 
. and designates them as fibro-plastic. By this term, he seems to imply 
that they constitute a transition stage towards fibrous tumors ; and the 
excellent detailed descriptions he gives of their structure, are, on the 
whole, confirmative of the same view. Nuclei, circular, and elongated 
cells, and fibres, make up the chief part of their structure — the fusiform 
cells being generally the most numerous. It is to be regretted that 
the tumors he examined were not tested, so as to ascertain whether 
gelatin could be obtained from them in quantity. If this had been 
the case, their fibrous character would have been decided. Among the 
tumors we have ourselves examined, those which seem to deserve best 
the name of sarcoma, as being unlike either to fibrous and carcinoma- 
tous growths, are certain enlarged lymphatic glands, whose structure 
consisted of multitudes of nuclei, set in a fibroid stromal substance. 
With these we should class certain separate tumors, entirely new forma- 
tions, which are rather soft or lax, of a whitish gray or light pinkish 
color, either smooth on the surface or lobulated, so as to resemble the 
pancreas. In structure, these are found to consist of myriads of nuclear, 
with a few celloid, particles, and some trace of fibroid stroma mingled 
with alarge proportion of faintly granulous matter, and more or less 
oily. These tumors contain notable quantities of gelatin and protein. 
Generally, we should conceive that a growth, consisting of cells or of 
nuclei, set in a non-fibrillated homogeneous blastema, would not yield 
gelatin, but albumen ; while one which consisted of fusiform cells or 
fibres, would have more or less completely undergone the chemical 
change which an albuminous blastema experiences in passing into the 
state of gelatinous fibre. The former, we should, therefore, consider to 
be properly termed a sarcoma, i. e. a simple growth, of like composition 
to flesh, or the albuminous blastema, effused from the blood, not having 
attained in its development any very special structural character. In 
proportion as it passed into the condition of a fibrous tumor, it would 
lose its sarcomatous character. Cyst formation, combined with sarcoma, 
constitutes cysto- sarcoma. This is said by Rokitansky to occur in three 
forms: (1) simple cysto-sarcoma; (2) cysto-sarcoma proliferum, in which 
young cysts grow on the inner surface of the parent, and are either 
sessile or pedunculated ; (3) cysto-sarcoma phillodes, distinguished by a 
growth of vascular, laminated, or watery or cauliflower-like excrescences 
projecting into the interior of the cyst. The structure of these growths 



CANCEROUS TUMORS. 187 

is sometimes more fibrous, sometimes more similar to that of gland 
tissue. In both cases, the foliated terminal portions are invested by a 
distinct limitary membrane, within which an epithelium is sometimes 
discernible. Cysto-sarcomata mostly occur in the female breast and in 
the ovary. 



CANCEROUS TUMORS. 

In attempting to give a sketch of cancerous or malignant tumors, we 
think the best plan will be to take a typical specimen, which presents 
all the characters of the genus strongly developed, and to point out 
what these characters are. We shall afterwards notice the several 
species, and endeavor to show how the distinguishing features gradually 
become effaced, until the formation, as often happens, is, or appears, 
almost identical with those of a benignant nature. A tumor, of the 
species called encephaloid, is certainly the Ttapabetyfia of cancer. It is 
of rapid growth, often attaining in a short time a very large size. Its 

Fig. 67. 




Encephaloid — The first and the last three of the sets are from the liver, the second is from a bone, and the 
third from the vertebral column. The great difference of the cell forms is very apparent. 

aspect, resembling very closely that of the medullary cerebral structure, 
has obtained for it the name just mentioned, as well as others of simi- 
lar import — medullary sarcoma, medullary fungus. Its color is an 
opaque white, often, however, varied in parts by patches of deep red, 
from vascular injection or hemorrhage. Its consistence is often so soft, 
that it seems semi-fluid, and gives the sensation of fluctuation. In 
structure, it appears on section often almost homogeneous, sometimes 
with a locular or fibrous arrangement. Microscopic examination shows 
that the main mass consists of celloid particles and cells, contained in a 
sparing quantity of filamentous tissue, which forms a kind of stroma. 
Such a tumor is seldom solitary, but coexists with other similar ones in 
the same and in different organs. If extirpated, it is sure to return, 



188 



CANCEROUS TUMORS. 



and probably diffuse itself more widely than before. It poisons the 
lymphatic current passing from it, and induces growths of like nature 

Fig. 68. 




Simple and compound cancer cells from cancerous duodenum. — Bennett. 

in the glands which that current traverses. It affects the general 
system with a peculiar cachexia, marked by languor, emaciation, debility, 

Fig. 69. 




Cells from Encephaloid of Tongue (rapidly growing). 



and a sallow complexion. It is very apt to infiltrate adjacent textures 
with its own substance, and, by absorbing their nourishment for itself, 
to occasion their atrophy ; and, lastly, it tends, when exposed, to break 



CANCEROUS TUMORS. 



189 



down by a kind of decay, and to pour out profuse, exhausting discharges 
of serous, sanious, or bloody fluid. Such is cancer in its most malignant 
form. Of the above-mentioned characters, those which seem to us most 
nearly pathognomonic, are the tendency to infiltrate adjoining parts, to 
affect the glands traversed by the issuing lymph- current, to reproduce 
similar growths in distant parts, and to return after removal. If these 



Fig. 70. 



Fig. 71. 



Fig. 72. 



Fig. 73. 



Fig. 74. 



;>l^ 



mmm 



taste %- w. ; 



c : ■■_.. ; ;i : -> v .->;v.- Q l ( V.W. 



& ft 






Figs. 70, 71, 72. Cancer-cells before and after the addition of acetic acid, also the structure of the reticula- 
tam from encephaloma of the testicle. 
Figs. 73, 74. Young cancer-cells before and after the addition of acetic acid. 

four characters are decidedly exhibited by any tumor, there can be 
scarce any doubt of its malignant nature. It is to be remarked that all 
these characteristics are dynamic and not structural. They result from 
the invisible qualities of the new formation ; its mode of vegetation, dis- 

Fig. 75. 




Fungus hsematodes. Fungoid, bleeding, and brood-like. From the mamma. 



semination, and reproduction, not from any peculiarity of form or 
arrangement of its particles. Whatever these might be, a tumor, which 
behaved as we have just described, would proclaim its cancerous nature. 



190 



CANCEROUS TUMORS. 



This point we shall illustrate further on. We now proceed to speak of 
the other varieties of cancer ; first, however, noticing the sub-varieties 
of encephaloid. The name mastoid is given to a kind of firm growth, 
which is thought to resemble on section the boiled udder of the cow. 
That of solanoid (potato-like) designates other hard cancers, resembling 
that vegetable when sliced. Dr. Walshe says they are a pale yellow- 
ish, of unctuous crisp look, and almost homogeneous. Milt-like has 
evidently reference to a soft, pale growth, containing scarce any blood. 
The surface of a section of Nephroid cancer presents a resemblance to 
that of a kidney, owing to the peculiar arrangement of its fibres, which 
are themselves of a delicate gelatinous transparency, so that Rokitansky 
calls the growth hyaline cancer. The term Hsematoid expresses a much 
more important feature than any of the preceding, as it implies that the 
growth is unusually vascular, is the seat of excessive development of 
vessels, and perhaps of blood, and is prone to pour out those alarming 
hemorrhages which often cause fatal exhaustion. When the hsematoid 
character is strongly marked, the name of Eungus Hsematodes is appli- 
cable. Melanoid cancer is, in the great majority of cases, encephaloid 
structure, with the addition of black pigment. The cell-growth of 

Fig. 76. 










Cells more or less loaded with black pigment, from a melanotic tumor of the cheek. — Bennett. 



encephaloid may consist of large free nuclei, of caudate cell-particles, 
of granulous globules much like those of pus, but unaltered by acetic 
acid, of cells of most various shapes, often irregularly caudate, and of 
pellucid vesicles. All these may be mingled in various proportion, or 
some may constitute the chief mass of a growth. The annexed cut, 
page 187, exhibits cell structures of various kinds ; and for more minute 
details we must refer to the trustworthy descriptions of Mr. Paget, 
page 368, vol. ii., of his published lectures. 

Scirrhus or hard cancer commonly appears as a knotty, or uneven, 
pretty distinctly limited, very hard (stony) tumor. Its surface or sec- 
tion is of a bluish or grayish white, and often presents a peculiar glossi- 
ness ; scarce any trace of vessels is ordinarily visible, except in spots, 
which are inflamed and softening. The adjacent tissues, especially the 
skin, when the growth is subcutaneous, are more or less involved, and 
drawn inwards towards the tumor. In structure, it consists essentially of 



CANCEROUS TUMORS. 



191 



a blastema, or basis substance, more or less advanced in fibre-development, 
in which very various forms of cell-growth are imbedded. Of the latter, 



Fig. 77. 



r.^M&UKk^ 



mtWJum 



Fie. 78. 



* 








,'M.i 



Fibroid stroma of a scirrhous tumor of Pylorus. 




Scirrhous tumor of cerebrum. 

A— Cells. 

B — Section of firm stroma. 



it is utterly impossible to give any general account, except to correct 
the common idea that they are of fusiform shape, they may be bare 



Fig. 79. 



Fie. 80. 




Fig. 82. Fig. 81. 

Fig. 79. Portion of the section from a carcinomatous tumor of the breast; consisting of fibrous tissue and 
cysts, inclosing cancer-cells and granules. A compound granular corpuscle is also visible. 

Fig. 80. Another portion of the same section treated with acetic acid. The fibrous tissue is rendered more 
transparent, and elongated nuclei are risible scattered through it. The nuclei of the cancer-cells are un- 
changed, while their walls are transparent. A compound granular corpuscle is seen at the upper part of the 
figure. 

Fig. 81. Cancer-cells from the cream-like juice squeezed from the tumor. Numerous granules, and a com- 
pound granular cell, are seen. 

Fig. 82. The same, after the addition of acetic acid.— From Bennett. 



192 CANCEROUS TUMORS. 

nuclei, cells of most various aspect, vesicles; granular globules; with 
these oil and diffused granulous matter are mingled in varying quantity. 
Glomeruli are often seen in fattily degenerating, or in inflamed parts ; 
and parent cells, containing a secondary generation, are occasionally 
present. The disposition of the fibres is very various, sometimes parallel 

Fig. 83. Fig. 84. Fig. 85. 




Fig. 83. Dense fibrous and elastic tissue, in which cancer- cells are infiltrated from cancer of rectum. 
Fig. 84. Cancer-cells scraped from the surface, in the same case. 
Fig. 85. The same, after the addition of acetic acid. — From Bennett. 

to each other, sometimes radiating, often crossing at right or acute 
angles. An alveolar arrangement sometimes exists ; it proceeds, accord- 
ing to Rokitansky, from the development of the parent cell. Scirrhus 
yields some gelatin on boiling; less albumen and oil, but more saline 
matter, are contained in it than in encephaloid. The growth of scirrhus 
is slow, the more so in proportion as its fibrous element predominates ; 
it may then exist long without inducing the constitutional cachexia, or 
reproducing itself in any distant part, or even affecting the lymphatic 
glands. The most common seats of scirrhus are the female breast, the 
pyloric extremity of the stomach, the rectum ; it is usually the original 
formation in these or in other parts ; but gives rise to secondary encepha- 
loid growths. A tumor of this kind does not, even when most defined, 
possess a true cyst ; often, it extends itself by infiltration among adjacent 
tissues. It rarely attains a large size, it is not often seen so large as 
an orange. Various names have been given to some peculiar appearances 
occasionally presented by scirrhous tumors ; of these, we shall only men- 
tion the napiform, applied to certain tumors whose cut surface presents 
a number of concentric lines, resembling those seen in the interior of a 
turnip; and the apinoid, or reticulated, in which spots or streaks of an 
opaque oily matter are apparent upon a grayish field, and thus occasion 
the appearance of separate patches, or of a network. It is ascertained 
that this latter condition indicates a commencing fatty change. The 
surface of an ulcerating cancer is irregular, of a grayish or faint reddish 
aspect, covered with a thin watery sanies, or with a layer of sloughing 
detritus; the margin of the surrounding skin is commonly elevated and 
everted. 

Colloid cancer, the next variety we notice, is also called alveolar ; 
other cancers may present more or less of an alveolar arrangement, 
but it never constitutes the prominent feature of their structure. The 
walls of the alveoli consist of a fibroid tissue, sometimes extremely deli- 
cate and translucent, sometimes, and especially in the deeper layers, 



CANCEROUS TUMORS. 



193 



strong and firm. The contained loculi vary in size from that of a grain 
of sand to that of a pea ; they are round or oval ; occasionally adjacent 



Fig. 86. 



Fig. 87. 





! 



Colloid cancer of a lymphatic gland. 

Of the two smaller figures, one exhibits the 
circular loculi as they appear on a section ; the 
other shows the compound spherical character of 
the malignant growth itself. 

ones communicate together by solution of the interposed wall. The 
jelly-like substance in their cavities is of a greenish yellow, semi-trans- 
parent, and clammy ; " it yields no gelatin on boiling, but seems to 
consist of a peculiar substance, identical with that naturally occurring 
in the cavities of the thyroid, and in some cysts. Cells, nucleated and 
non-nucleated, caudate, and fusiform, nuclei, and elementary granules, 
occur in this substance, and, under circumstances probably connected 
with softening changes, granule-cells, and fat-molecules. Endogenous 
production of the cells within parent-cells is sometimes observed. Colloid 
may present itself as a distinct solitary tumor," or may infiltrate the 
tissues which it infests, when it occurs on serous membranes ; there are 
often small scattered nodules of the growth in the vicinity of the larger. 
Hokitansky mentions the two following varieties of colloid : (1.) The 
contents of the loculi increase, so that their septa are in great measure 
atrophied and lost, and the mass presents the aspect of a tremulous 
jelly. (2.) The superficial alveoli enlarge considerably, and attain a 
prodigious size. The favorite habitat of colloid is the stomach and 
omentum ; it also occurs in the ovaries, the bones, the kidneys, the 
uterus, and the spleen. Its growth is often rapid, and it may attain a 
very large size, exceeding that of a cocoa-nut. The contents of the 
alveoli are sometimes of pearly aspect, probably from the presence of 
cholesteatomatous matter. Cruveilhier has described an areolar pul- 
taceous variety, in which the loculi contain an opaque, yellowish, tal- 
low-like matter, having the chemical constitution of casein. This 
we believe, with Hokitansky, to be a condition in which fatty trans- 
formation of the gelatinous matter is taking place analogous to that 
noticed in reticular scirrhus. Colloid may exist combined with scir- 
rhus, and also with encephaloid; in the latter case, the superficial 
loculi become occupied by soft encephaloid matter. The malignant 
13 



194: 



CANCEROUS TUMORS. 



character is less marked in colloid than in the other kinds of cancer ; 
it does not induce such marked cachexia, does not reproduce itself in 
distant parts, does not contaminate the lymphatic glands, and is less 
prone to softening and decay, or to inflammation and saniation. 

Epithelial cancer seems only recently to have been admitted among 
the varieties of this disease ; it is not mentioned by Dr. Walshe in his 
elaborate work, and yet its cancerous nature in many cases is unequivo- 
cal and strongly marked. It occurs almost solely on tegumentary or 
mucous surfaces, the lips and cheeks are among the parts most com- 
monly affected by it. Rokitansky mentions having once observed it in 
the liver, and Dr. Bennett has met with it as a secondary growth in the 

lymphatic glands. On mucous surfaces it 
Fi g- 88 - appears as a cauliflower-like growth, of a 

more or less red tint from vascular injec- 
tion, of various degrees of consistency, 
and easily separated into parts by press- 
ure. On the general tegument, its appear- 
ance is most often that of a low, tolerably 
well-defined tumor, of hard feel, having an 
irregular nodulated surface, covered with 
minute watery papillae; when ulceration 
and softening take place, the surface be- 
Epitheiiai cancer. comes injected, a watery and serous dis- 

charge is poured out, and gradual de- 
struction of the part proceeds. In structure, these tumors essentially 
consist of an alteration of the integument, the corium and subcutaneous 




Fig. 89. 



N 







Ift IP 



Appearance of section of cancerous tumor of the cheek, a. Epidermic scales and fusiform corpuscles on 
the external surface, b. Group of epidermic scales, c. Fibre-elastic tissue of the dermis, d. Cancer-cells 
infiltrated into the fibrous tissue, and filling up the loculi of dermis. (From Bennett.) 



areolar tissue being converted into a fibroid substance, the papillae 
greatly hypertrophied, as well as the epithelium resting upon them. In 
the last specimen we examined, which was from the lower lip, a vertical 
section displayed an external whitish layer, about one-third inch thick, 
marked by vertical striae, and resting upon some areolar tissue, fat, and 
muscle. Its surface showed but slight traces of subdivision. Its ex- 
tent in depth appeared to be most accurately limited by the lower 
margin of the whitish striated layer, but, upon examination, the areolar 
tissue immediately subjacent, and for some depth, was found thoroughly 



CANCEROUS TUMORS. 



195 



infiltrated -with nuclei and granular matter. Sections of the altered 
integument showed papillary elevations, completely overwhelmed and 
blended together by an enormous growth of scaly epithelium, which, in 
some parts, showed a tendency to fatty change, and here and there the 
capsulating arrangement mentioned below. If glands exist in the part 
affected, their epithelium may also accumulate within their canals, 
and thus add to the size of the tumor. One peculiarity is very com- 
monly observable in the arrangement of the cells of epithelial cancer, 
which does not seem to occur in other growths ; this is, that here and 
there the scaly particles are arranged in lamellae around a central cir- 
cular space, which appears to be a largish cell, containing a younger 
cell-growth. The malignant character of epithelial cancer is mani- 
fested in its extending from the superficial textures first involved to 
the deeper seated, even to the bones; the laryngeal cartilages have 
often been involved by it. It seems, however, to have less tendency to 
contaminate the lymphatic glands, and the system generally, than other 
varieties of cancer. Rokitansky describes a variety of cancer, which 
he calls villous, from its consisting of a kind of delicate fibrous stalk 
branching at its end into villous processes, with somewhat bulbous 
terminations. These contain encephaloid substance, and are extremely 
vascular. Hemorrhage often takes place spontaneously from them, and 
is easily excited by the slightest lesion. The only specimen at all cor- 
responding to this which we have examined, was one of cauliflower 
excrescence of the uterus ; it was not in a suitable state for accurate 



Fig. 90. 




Epithelial cancer — four of the loculi are shown, and some of the flattened cells, one of which is curved, 
having prohahly been arranged round a loculus. 

investigation, but we saw that it consisted in great measure of large 
vessels, covered with a thick layer of lowly organized cell-growth. 
Rokitansky mentions a case of this kind, in which the growth sprang 
from an evidently encephaloid base. A cystic growth sometimes 
occurs in combination with one or other of the species of cancer, 
chiefly with encephaloid: the cysts may be simple or compound. 
The cysto-carcinomatous growth is usually of large size. There 
may be, probably, other varieties of cancerous tumors, or, to put 
it otherwise, tumors possessing more or less of cancerousness ; but 
we have now sketched the outline of the principal forms that are 
usually met with, and we feel convinced that it is far more important 



196 CANCEROUS TUMORS. 

for the student and the practitioner, to contemplate steadily the great 
characteristics of cancerous disease, than to load his memory with de- 
tails of the incidental and trivial. Partly on this account we have not 
attempted to give any very minute description of the structure of can- 
cerous tumors, for our own examinations have most thoroughly convinced 
us of the non-existence of any special structural character, absolutely 
and in all cases distinctive of cancer. This point, which is in accordance 
with the teaching of the best authorities, seems far from being correctly 
understood in the present day, and we cannot but think that there is 
still much tendency to over-estimate the microscope as a means for the 
diagnosis of cancer. It is our opinion that the cases are very rare 
indeed, where the microscope will avail to detect cancer with any cer- 
tainty, where the naked eye features are insufficient. On the other 
hand, we have more than once seen unquestionable cancers made up of 
substance which we should have been led, from microscopic examination 
alone, to consider as of a simple nature. What may be said relative to 
the distinguishing of cancerous from other tumors, by their mere physical 
characters, and not by their living actions, amounts to this: If a tumor, 
on being incised and compressed, yield a whitish, milky juice, (the so- 
called "sue cancereux") it is probably malignant; we have, however, 
failed to obtain this sign from actual encephaloid. If the cell-growth of 
a tumor is what may be called exceedingly multiform, i. e. one particle 
unlike another, the field of view being filled with other varieties of shape 
and construction, there arises a strong presumption that the structure is 
malignant. If a tumor consist of an abundant cell-growth lying in a 
basis substance of slight consistence, and containing very little fibre, it 
so far bears a close resemblance to encephaloid. If, on the other hand, 
a tumor consist chiefly of fibre or fibrillating blastema, the presumption 
of its cancerousness diminishes; we have, however, seen a growth in the 
liver, which had all the aspect of a scirrhous formation, and probably was 
so, which yet consisted solely of fibre-forming solid blastema. If a tumor 
infiltrate adjacent parts, it is probably malignant, but all cancers have not 
this character. The presence of large cells, containing several nuclei, 
similar to those figured by Lebert 1 and Bennett, 2 would be a strong ar- 
gument for the cancerous nature of the tumor, from whence they pro- 
ceeded. So also we should regard the development of a nucleus into a 
large granulous globule or vesicle, or into any structure very dissimilar 
to its original condition, or that of the nuclei of natural tissues. In 
concluding these general remarks, we may state, we think, the following 
position with some confidence, viz: that, starting from encephaloid as 
the representative of cancer par excellence, we find the cancerous cha- 
racter gradually declining as we pass through a series of formations, 
such as we have above described, until we come to those of whose inno- 
cent nature there is no question. The exact limit, we believe, at which 
cancerousness is lost, cannot be marked by any characters of a growth 
itself. The vessels of cancer, for the most part, we believe, are of the 
ordinary kind, derived from those of the natural tissues by the process 

1 Phys. Patholog. PL xxi. fig. 5. 

2 On Cancerous and Cancroid Growth. Figs. 69 and 117. 



CANCEROUS TUMORS. 197 

of extension or growth ; sometimes, however, it seems that blood and 
vessels are formed in the blastema of a tumor, as we have described 
them to be in exudation matter; this we consider is most likely to be 
the case in growths of the haematoid character. The blood contained 
in the developing vessels is seen, as it is said, to oscillate in them before 
they have anastomosed with those of the general system. No special 
formation of lymphatic vessels or nerves, seems to take place in cancer- 
ous tumors. The lymphatic vessels of the part affected, no doubt, 
act as absorbents of the redundant blastema, as is amply shown by the 
special contamination of the glands, to which those vessels immediately 
proceed. The nervous filaments traversing or distributed to the part 
which is the seat of the cancerous growth, are often involved in the 
mass, and becoming injuriously pressed on, or otherwise injured, occa- 
sion the most frightful pains. There is scarce anything accurately de- 
termined, respecting the chemical composition of cancer. Encephaloid 
is said to consist chiefly, if not entirely, of albuminous matter; Scirrhus 
to contain gelatin also, while colloid jelly seems to be a principle quite 
sui generis. Possibly, there may be some special cancerous virus, as 
there is a variolous and syphilitic, but as yet chemistry knows nothing 
of it, and we only infer their existence from the effects they produce. 

[The subject of cancer and its microscopic diagnosis being one of deep 
interest, we present here the illustrations of cancerous structure from 
the valuable paper of Dr. Francis Donaldson, of Baltimore, Maryland. 
See Am. Journ. of Med. Sci., vol. xxv. p. 43. 

" It is improper," remarks Dr. D., "to attempt to divide cancer into so 
many species, as they all have the same common pathology. The variety 
of aspect^consistence, volume, coloration, and vascularity, is caused merely 
by the amount of fibrous element, of fat, or of gelatinous fluid present ; 
all of which are purely accidental, and in no way essential to constitute 
the growth. The density, softness, &c, may also vary according to the 
organ involved ; the breast and the pylorus take generally the form of 
scirrhus; whereas the bladder, the kidneys, &c, are more likely to be 
affected with encephaloid. Compare the physical characters of cancer 
with those of the simple tissues, such as the muscular, areolar, dartoric, 
osseous, &c, or with those of the compound, as the glandular, the syno- 
vial, the mucous, &c, and the difference will be very apparent. Its 
greater or less firmness, its homogeneous fibrous aspect with its lacte- 
scent infiltrated juice, are very characteristic. The presence of this 
peculiar fluid is of itself a point of differential diagnosis of great value; 
the microscope always detecting in it, when found, the presence of cancer- 
cells, &c. No matter what organ is the seat of the disease, this fluid 
can generally be scraped from the cut surface, or squeezed out by gentle 
pressure. It is particularly abundant in encephaloid, and frequently 
oozes out in drops having a white cloudy appearance of the consistence 
of cream, and very much of its color, being slightly tinged with yellow. 
It may sometimes, on superficial inspection, be confounded with light- 
colored pus, which has, however, with the yellow, a slightly greenish 
tinge. If, from the conditions of its formation, there can be any doubt, 
an appeal to the microscope will at once settle it by giving us the charac- 
teristic pus-globule. (See Figs. 99 and 100.) 



198 CANCEROUS TUMORS. 

"The cancer juice forms readily an emulsion with water, and in this 
differs from tubercular matter and from that pressed from sebaceous 
tumors. The color of this juice is of course modified by the mixture of 
other fluids with it ; thus, when the vascularity is great, it is often red- 
dish ; when from a deposit of dark pigment, we have what is called 
melanotic cancer, it becomes of a dark brown. When mixed with 
much fat, it is more consistent; in colloid, it is thicker and sometimes 
grumous." 

"In the accompanying figures, we have," says Dr. D., "attempted 
to arrange (under several divisions), into groups, the different forms of 
the cancer-cell we have met with. In making the selection from the 
numerous drawings we have collected in our album, we have thought it 
better, instead of giving only the types, so to speak, of the several 
shapes under which we desired to include all the various modifications, 
to show as many as possible of the numerous varieties. For the rude- 
ness of the designs themselves we ought, perhaps, to apologize, but they 
are, as far as we could make them, exact representations of what we 
saw in the field of the instrument. We will first describe the proper 
elements separately, and then speak of the objections offered by Dr. 
Bennett, and some others, to their distinct characters as pathognomonic 
of cancer, giving drawings of other elements confounded with them. 
The points of dissimilarity we will call attention to with a view of fixing 
the differential diagnosis. The mode we have employed has been simply 
to place between two pieces of glass a drop of the juice, obtained either 
from gentle pressure, or by scraping the cut surface with a scalpel, 
diluted with a little water. The cutting off of small slices with Valen- 
tin's knife, and examining the whole mass together, will exhibit, almost 
invariably, more or less fibrous structure, but necessarily the lens em- 
ployed must be much feebler, and the cell is not seen to the same advan- 
tage ; moreover, the fibrous element is purely accidental, and is found 
in a vast number of tumors. The instrument used is a first-class one, 
manufactured by Nachet. The power we have habitually used in study- 
ing cancer element has been one of 555 diameters (Nachet's No. 6). 
Mr. Bennett used, in his researches, one of 250, which he recommends 
to others. We state this for the purpose of explaining why it is he has 
omitted some characters of the element which we believe are of great 
importance. The element of cancer consists of three parts, cell, nucleus, 
and nucleolus, all of which are peculiar to it. We will consider — 

"1. The cancer nucleus, as inclosed in a cell, or as floating free by 
itself. 

"2. The polygonal, or more or less spherical and ovoid cell. 

" 3. The caudated cell. 

"4. The fusiform cell. 

"5. The concentric cell. 

" 6. The compound, or mother cell. 

" 7. Agglomerated nuclei connected by amorphous tissue. 

"In all the varieties of cancerous tissue, nuclei are to be found either 
enveloped by a cell, or floating free, generally more or less of both ; in 
some specimens, there exists a large number of free nuclei witfy only an 
occasional cell. The form and appearance of these nuclei is the most 



CANCEROUS TUMORS. 199 

constant and unvarying of all cancer elements. They are, Fig. 91, a, 
ovoid, or more or less round ; the latter are found more particularly 
when the eye or the lymphatic glands are the organs diseased. Some- 
Fig. 91. 




Free cancer nuclei, a. Type form. b. The same, with a piece nicked out of the side accidentally, c. Shows 
a free nucleus, in which the molecular granules are very minute, often met with in perfectly fresh specimens. 
d. A nucleus, in which larger granules have commenced to form. e. The characteristic nucleolus with its 
dark contour and bright centre, h. Fine molecular granules, i. The second variety of granules, or gray 
granulations, j. Fat granules. 

times (as in b\ we find little pieces of the wall of the nuclei apparently 
nicked out ; but evidently it is purely accidental, and the proper shape 
can easily be recognized. They have, ordinarily, in width, a diameter 
of from l-100th of a millimetre, or (a millimetre being equal to .039th 
of an inch) of .0039th of an inch, to l-66th of a millimetre, in one 
instance we met with one as wide as l-38th of a millimetre ; in length 
they measure from l-133d to l-100th of a millimetre. Their con- 
tour is dark and well defined, with the interior containing very minute 
dark granulations ; indeed, when the specimen is perfectly fresh, they 
have a homogeneous aspect, the granulations being so small as to give 
the appearance of a mere shading (as in c) ; if the specimen is kept a 
day or two, we find the interior filling up with larger granulations (as 
in d). Within these nuclei, when they have not been obscured by 
granular or fatty degeneration, there is found habitually a small body, 
or nucleolus, averaging in diameter about l-500th of a millimetre. 
These nucleoli have somewhat of a yellowish tinge, with a brilliant 
centre and dark borders, refracting light like the fat-vesicles. We 
would call attention, particularly, to the peculiar brilliancy of the cen- 
tres of these nucleoli, which, we think, is characteristic ; it can be almost 
invariably noticed, if the focus is varied. Their large size, in propor- 
tion to the nuclei, should also be noticed, together with the great varia- 
bleness of their position, sometimes being near the centre, and again in 
close contact with the walls (see e). Ordinarily, in other elements, they 
are found almost constantly in the centre. Very frequently, two or 
three nucleoli are found within the same nucleus. M. Robin 1 mentions 
the action of acetic acid upon cancer nuclei and their nucleoli, as differ- 
ing from that on other elements, particularly epithelial; it renders the 
nucleus gradually paler, together with the cell, destroying neither — but 

1 MS. notes of his Cours de Histologie, 1850. 



200 CANCEROUS TUMORS. 

the nucleolus is perfectly untouched by it ; whereas in epithelial cells, 
where generally in those of the skin the nucleoli are wanting, the action 
of acetic acid destroys the cell, leaving the nucleus unaltered." 

u It is of primary importance for the proper examination of the cancer 
nucleoli that the specimen should be fresh. Such being the case, we do 
not remember ever having found these peculiarities wanting." 

" We have examined some specimens in which free nuclei were in great 
abundance, and where, after long-continued diligent search, we were 
unable to discover any cells. More particularly is this the case in can- 
cer of the liver, of the pylorus, and of the lymphatic glands ; more rarely 
in that of the eye. In the breast, many full-formed cells are found with 
more or less of free nuclei floating in the blastemic fluid. It may be 
well to remark here that we find also free nuclei of fibro-plastic and 
epithelial cells, of the finest bronchial ramifications, each with their 
peculiarities. Mr. Bennett appears to us to have confounded them all 
together in speaking of what he calls fibro-nucleated tissue. 

"In regard to the cells themselves of cancer, although we stated their 
forms as very variable, yet many of them are modifications of the poly- 
gonal, which may be considered the type. In explanation of the theory 
of the shape and size of various cell-membranes, we would refer the 
reader to Professor Schwann's views; 1 undoubtedly, as he supposes, the 
close crowding together, and the processes of endosmose and exosmose, 
may be the producing cause. Thus, we observe that in hard firm tumors, 
particularly those of the breast and ovaries, the cells found are exceed- 
ingly irregular, sometimes nearly triangular, Fig. 92, /. The ovoid or 
spherical are more frequently met with in soft or medullary cancer, Fig. 
92, g, where there is but little pressure, although its juice appears often 
to be but one mass of cells. It is rare, however, that perfectly round 
cells are met with, but very generally the angles are well rounded in 
those which appear to be derived directly from the polygonal form, the 
diameter of which is very variable, ordinarily from ^th to ^th of a 
millimetre. One peculiarity of this, as of the other forms of cancer-cell, 
is the presence of the granulations of different sizes in their interior ; 
whereas, in epithelial cells, the interior is generally, when fresh, of 
course, homogeneous. In cancer, we find the three varieties of granu- 
lations given by M. Robin ; 2 first, the very fine black dots found in all 
organic elements, and named by the French, very appropriately, pous- 
siere organique ; secondly, the gray granulations, a form somewhat 
larger ; and, lastly, the fat granulations distinguished by the refraction 
of the light. — This first variety of cells contains nuclei, having in their 
interior invariably one or more nucleoli, both of which retain the charac- 
teristic points described above. The large size of the nucleus, in pro- 
portion to the diameter of its cell, will at once strike the eye of the 
careful observer. The variable position, also, of the nucleus within the 
inclosure, appears to us to be peculiar to cancer ; in cells of other struc- 
tures, the rule is to find the nucleus very nearly in the centre, except 
with fibro-plastic cells, where the nuclei appear to have a peculiar affinity 

1 " Microscopical Researches into the Accordance in the Structure and Growth of Ani- 
mals and Plants," by Th. Schwann. Sydenham Soc. edit. 

2 Tableaux de Anatomie, &c, par Ch. Robin. Paris, 1851. 



CANCEROUS TUMORS. 



201 






for the walls. All varieties of cancer-cells contain very frequently two 
or more nuclei ; whereas, the epithelial, more particularly those found 

Fig. 92. 




Forms of cancer-cells derived from the polygonal or type variety, g. Spherical cells, a. Dark contour of 
inclosed nucleus, e. The nucleolus. 7.-. A nucleus with its contour pressed out of shape. I. A form of cell 
frequently seen, where there is a deficiency of part of the wall. f. From pressure rendered triangular. 

on the surface of the body (where there is most danger of confusion and 
doubt), but rarely have more than one. Moreover, the cell of epithelium 
is much larger than that of cancer, yet the cancer nucleus is twice as 
large as that of epithelium, as is also the nucleolus, compared with that 
found in epithelium. 

" Caudulated Cells. — This variety of cancer element appears to be 
considered the cancer-cell by persons unfamiliar with the microscope. 
The French pathologists speak of it as la cellule en raguette, Fig. 93. 
Its general aspect is the same as that of the preceding, the only difference 
being the prolongations, one, two, or three in number, branching off from 
the body (so to speak) of the cell ; sometimes there are as many as five 
projections. There is no regularity about them, as the reader may 
perceive in the plate ; indeed, they frequently take the most grotesque 
shapes. 

"This form is met with more or less in all cancerous tumors, but in- 
variably in those of the bladder ; cancerous degeneration of the parotid 
often contains them in considerable abundance. 

"Fusiform Cancer- Cells. — (Fig. 94.) This shape is caused by a swell- 
ing in the centre, with the ends pointed, forming often a very acute 
angle. It is found mixed with the other forms in all parts of the body; 
but always more numerous in cases where the disease has attacked the 
bones. M. Robin 1 says that he has never examined cancer of the bones 
without finding this variety. It is this form which Mr. Bennett confounds 



1 MS. Notes of his Cours d'Histologie, 1850. 



202 



CANCEROUS TUMORS. 



with fusiform fibres of fibro-plastic tissue (Fig. 95), making no distinction 
between them, but describing them together under the name of fusiform 




Caudated cancer-cells, to. The most usual forms, n. Cells containing double nuclei ; cancer of the bladder 
invariably contains this variety. 

corpuscles. Except some similarity of shape, we cannot see how they 
could be mistaken for each other. We ask the reader to compare the 



Fig. 94. 



Fig. 95. 





Fusiform cancer-cells, found in great abund- 
ance in cancerous disease of bones, a. The nu- 
cleus, wbich, in this variety of cell, is almost con- 
stantly ovoid. The transverse diameter of the cell, 
and the size of the nucleus in proportion to the 
cell, together with the characteristic nucleolus, 
distinguish this variety from the fusiform fibro- 
plastic element. 



Fusiform corpuscles of fibro-plastic tissue. 4. The 
narrow and long fusiform cell, containing a nucleus 
(5) with a small dot in its centre for a nucleolus ; ave- 
rage length of cell l-12th millimetre. (Magnified 555 
diameters.) 



CANCEROUS TUMORS, 



203 



Fig. 96. 



drawing of these two things, and he will at once see that the cancerous 
is double in width and length; moreover, its nuclei are much larger, and 
the nucleolus is much smaller in the fibro-plastic, where the absence of 
the clear bright centre, &c, may be noticed. 

The Concentric Cancer-Cell, Fig. 96, is formed of an ovoid or spherical 
body, surrounded by concentric rings, so as to give the peculiar appear- 
ance of circles around a centre, increasing in size as they get further 
out. The centre resembles in every respect the ordinary cancer nucleus, 
and sometimes other nuclei appear between 
the circles, and occasionally a nucleus is seen 
pressing against the outside of the cell wall. 
It is not known how this variety of cancer 
constituent is formed, and we forbear giving 
any of the conjectures in regard to them. 
Sometimes a mass of epithelial cells are 
pressed together, and present somewhat this 
appearance. This cell is met with but rarely, 
and but few in a specimen ; it is more likely 
to be seen, says M. Kobin, in the uterus, 
breast, and ovaries, than elsewhere ; it never 
forms the basis of the tumor, but is merely 

accessory. According to Robin, it exists more frequently in the form of 
cancer tissue, which, in consistence, is between scirrhus and encephaloid. 

" Having ourselves but one drawing of a distinctly marked specimen 
of this cell, we borrow for our plate one from M. Lebert. 1 

" The Compound or Mother Cell of Cancer, Fig. 97, is of very varia- 




Two concentric cancer-cells, a. The 
cancer nucleus, the size of which is al- 
ways in proportion to the innermost cir- 
cle, e. The brilliant nucleolus. 



Fig. 97. 




Compound cancer-cells, containing three or more nuclei, a. Nucleus ; when there are more than one nucleus 
within a cell they are smaller than the single nucleus, o. From Lebert. 

ble shape, as the drawings show. They have received this name from 
the views entertained by some authors, more particularly Kuss and 



Physiologic Patkologique. Atlas, Plate XVIII. 



204 



CANCEROUS TUMORS. 



Fig. 98. 




Bruch, of their splitting up into smaller segments and multiplying by 
division. They contain often three, four, or more cancer nuclei. We 
ourselves have never seen more than seven within one cell, although 
Lebert gives a drawing of one containing as many 
as nine. Some consider that secondary cells are 
formed within the parent one, and are let out by 
the rupture of the outer wall. It is, however, 
mere conjecture. — The last form in which these 
elements are exhibited is where a number of nuclei 
appear to be glued together, as it were, by the 
amorphous blastema in which they are generated, 
without there being any recognizable cell-wall 
around them. M. Robin 1 calls them plaques d 
noyaux multiples. The size of the envelop about 
them prevents them from being confounded with 
anything else. These agglomerated nuclei (Fig. 98) are nearly as rarely 
met with as the concentric cell. 

" All these varieties of cancer element can be seen in the same speci- 
men, although, as we mentioned in speaking of each, they have sepa- 
rately organs of selection. Cancer-cells, of course, like homomorphous 
elements of the organized animal or plant, have their periods of growth, 
and development, and decay ; their progress to maturity may be some- 
times arrested, and account to us in some measure for the great variety 
of appearance, structure, and size. For some interesting remarks, in 
regard to the retrograde metamorphosis of all tissues, both normal and 
pathological, we would refer the reader to an article by Dr. Burnett. 2 
" Out of the body, cancer elements change very rapidly, more so than 



Agglomerated nuclei, a. Nu- 
cleus, p. amorphous uniting 
tissue. 



Fig. 99. 



Fig. 100. 




Pus-corpuscles, magnified 833 diameters, q. Type 
form before the addition of any reactive, r. Outline 
of nucleus seen surrounded by thick granulation?. 



The same after the application of acetic acid. s. The 
irregular contour of the corpuscle freed from the 
granulations, leaving the nuclei clear, t. Character- 
istic nucleus without any nucleolus, u. Free nuclei, 
the walls having been destroyed. Diameter of pus- 
corpuscle varies from l-100th to 1-S0th millimetre, 
that of the nucleus l-333d. v. Remnant of contour. 



1 Tableaux d'Anatomie, 1851. 

2 American Journal of the Medical Sciences, July, 1851. 



CANCEROUS TUMORS. 



205 



any one element we have met with. Often, in the course of the first 
day, they become degenerated by the appearance of fatty granulations, 
which often hide their distinctive characters. Unfortunately, they can- 
not be preserved in any fluid. Alcohol coagulates the albuminous cell- 
wall. Mixed up with what we have designated cancer elements are often 
found crystals of cholesterin and of triple phosphates of ammonia and 
magnesia, filaments, fat-globules, crystals of margarine, pus (Figs. 99 
and 100), &c. Wherever there is inflammation, especially of a chronic 
character, we are apt to find fibro-plastic elements ; consequently, we 
must not hastily conclude, because we find them in a tumor, that there is 
nothing else there. The importance, therefore, of examining thoroughly, 
as far as possible, each portion of the specimen, cannot be urged too 
much. If but one cancer-cell be found, it is conclusive. That which 
has been designated melanotic cancer, is merely a mixture, with true 
cancer elements, of free pigmentary granulations, or of the peculiar cells 
of pigment." 

"We give, however, that others may compare them, the histological 
elements with which Mr. Bennett thinks cancer can be confounded. 



Fig. 101. 

v 



Fig. 103. 



WZ 






Fig. 102. 





Fig. 101. Young epithelial cells (from Lebert's plate), w. Cell-wall filled with, few and small granules, x. 
The nucleus, very small in proportion to cell, and containing no nucleolus. 

Fig. 102. Tessellated epithelium, y. Nucleus without nucleolus, diminutive in proportion to cell. z. The 
cell with homogeneous minute granulations filling up the centre. Diameter of the cell when taken from the 
skin l-10th millimetre. 

Fig. 10.?. Buccal epithelial scales, magnified 555 diameters, to show more clearly their dissimilarity to cancer 
elements. 11. Irregularly polygonal contour. 12. The characteristic nucleus without any appearance of a 
nucleolus, which is rarely met with in epidermic cells, or in those coming from the buccal surface. 

"Fibro-plastic elements possess a peculiar interest in being the only 
ones where there is any ground for seeing a resemblance to cancer ele- 
ments. They were first defined by M. Lebert, who thought them always 
the product of disease. Further researches have convinced him that 
such is not the case. In the healthy subject, they are found in the 
bladder, ovaries, liver, mammary gland, uterus, &c. According to 
Robin, 1 the internal membrane of the Graafian vesicle is the only mem- 
brane, in the state of health, which is formed altogether of it." 



MS. Notes of his Cours d'Histologie, 1850. 



206 



CANCEROUS TUMORS. 



"We give the true fusiform corpuscle (Fig. 95) of this tissue, the 
length of which is often as much as from ygth to -g^st of a millimetre. 
The narrowness of their width, the smallness of their nuclei, the nucleo- 
lus, and, indeed, the whole aspect, would prevent, we should think, any 

one who is familiar with microscopic inves- 
tigations, from confounding them with any- 
thing else. The fibro-plastic cells and their 
free nuclei (Fig. 104) could be mistaken for 
cancer by a superficial observer. They are 
ovoid, and sometimes polygonal, varying in 
diameter from 2 J ^th to ^g th of a millimetre. 
The appearance, however, of the nucleus 
itself with the nucleolus, differs very widely 
from cancer, the granulations in their inte- 
rior are very much finer, and of more uni- 
form size than those found in cancer. The 
free nuclei of fibro-plastic tissue are so 
much smaller as to be easily known when 
met with." 

" Mr. Bennett tells us, that when enchon- 
dromatous tumors become softened, and the 
cells escape from the cavities, they resemble 
very closely cancer. It has never been our good fortune to meet with 
any such cases ; but we confess we cannot understand how, even if the 
cells were free, they could be taken for those of cancer. Compare them 
(Figs. 105 and 106) with any or all of the varieties of cancer element, 
and remark the difference of shape, &c. 




Spherical fibroplastic cells, found in the 
uterus and in other organs in the healthy- 
subject ; also as the result of chronic in- 
flammations ; and forming, with the pre- 
ceding variety, the basis of true sarcoma- 
tous tumors. 6. Well-marked cell. 7 and 
8. Nuclei inclosed in cells or floating free ; 
transverse diameter l-200th millimetre. 



Fig. 105. 



Fig. 106. 



te J3 



%^n 





Cartilage elements taken from the condyles of the 
femur. 13. Hyaline tissue. 14. Excavated cavity. 
15. Cartilage cell. 16. Nucleus. 17. Nucleolus very 
frequently drowned by the fatty granulations. 



Costal cartilage. 18. Hyaline substance. 19. Car- 
tilage eavity. 20. Cell. 21. Nucleus. 



"In Fig. 99, we have given a drawing of pus, before the addition of 
any reactive, and, in Fig. 100, we have given the same corpuscles, acted 
upon by acetic acid. It will be noticed that with a high power, fre- 



CANCEROUS TUMORS. 



207 



quently a dim outline of the nuclei can be seen when the corpuscles are 
unmixed with any reagent. We are glad to have the support of Ben- 
nett and Robin in stating that there is no mucus-corpuscle. What has 
been so called was either pus, so easily produced on mucous membranes, 
or epithelial nuclei. 

" Thinking it would be not uninteresting to the reader to compare the 
element of tubercle with that of cancer, we give (Fig. 107) several cor- 



Fig. 107. 



Fig. 108. 









Corpuscles of tubercle (833 diameters). 1. Corpus- 
cles found in softened tubercular matter ; a small, ir- 
regularly formed globular body, -with neither nucleus 
nor nucleolus, measuring l-142d millimetre in dia- 
meter. 2. Interior granulations. 3. Free loose granu- 
lations. 



Cylindrical and ciliated epithelial elements, found 
in the nasal fossae, trachea, Eustachian tubes, in the 
intestinal canal below the cardiac orifice. 9. Hair- 
like extremities, which, during life, are constantly 
in motion. 10. Nucleus clear in the centre. 



puscles found in a specimen of softened tubercular lung handed to us 
while copying off these remarks ; from the first preparations examined 
we could have given almost any number, but the few we have drawn are 
perfect type specimens."] 

The origin of cancer is a subject of the deepest interest, but the first 
and most important step of the process is entirely concealed from us. 
M. Simon views a cancer as "substantially a new excretory organ," a 
growth which arises for the purpose of eliminating from the system an 
unhealthy matter which is generated within it. Such a function, how- 
ever, is surely not fulfilled by all instances, even of encephaloid, and 
still less of the other species. It rather seems that we should recognize 
in cancer a grave alteration of the normal formative powers ; those real, 
but occult influences which determine that — here bone, and there muscle, 
and there nerve shall be produced. We know something of the dis- 
turbances of nutrition occasioned by unhealthy conditions of the blood 
quoad its chemical composition; we know something of the origin of 
rheumatism, and gout, and syphilis, and of the effects they produce, 
but they are very different from the phenomena of new formations. 
Surely, the arising of a fibrous tumor, an enchondroma, or a cancer, 
implies a very different kind of action to that which is observed in any 
blood disease. We certainly believe the blood to be affected, probably 
in its chemical composition, as well as, and most importantly, in its 



208 CANCEROUS TUMORS. 

vital endowments, but we do not think it is the only seat of primary 
alteration. Were it so, how would it be possible to account for the 
constant preference manifested by scirrhus, and by other tumors, for 
particular sites ? We conceive, then, that in the case of cancer, the 
blood and the general system, but especially some particular part, 
having suffered some unknown deterioration or perversion of their vital 
power, a minute quantity of blastema, exuded in the specially weakened 
part (perhaps in consequence of a blow or other injury), commences to 
develop cell and fibre structure, which soon constitutes a new growth, 
endowed with powers of assimilation and vegetation to an almost in- 
definite extent. The tendency to cancerous disease, that is to say, the 
deterioration of the blood, and of the assimilative powers, may exist 
for a long time before it expresses itself in the tangible reality of a 
tumor; but when this is formed it becomes an engine for multiplication 
of similar tumors, and intensification of the cancerous diathesis. We 
have spoken of cancer as resulting from the development of effused 
blastema, and this, there is good reason to believe, is invariably the 
case ; in the vast majority of instances, the growth manifestly originates 
in the interstices of textural elements ; in some few it has been found 
in the coats of the veins, but in none has it been certainly proved to 
have originated in the blood. Cancerous growths have, indeed, been 
seen within the veins, but this has been the result of perforation of 
their walls by formations external to them. Development proceeds in 
cancerous blastema just as it would do in healthy ; nuclei and fibres 
seem to arise in the same way. The former are produced, we believe, 
with great rapidity, not by any slow process of building up by coalescing 
granules, but by the formation, at once, of a small spherical body, 
s^hoo i ncn m diameter, which subsequently enlarges, and presents the 
sharply defined envelop and the clear central cavity w T ith nucleolar 
spots, which characterize all nuclei. Often, however, the abnormal na- 
ture of the formative process displays itself in the irregular forms which 
the nuclei assume, becoming largish vesicles or granular globules ; or, 
if they have become included in a surrounding cell, enlarging, so as to 
represent a cell themselves, while secondary nuclei appear in their 
cavities. The encasement of several nuclei in one cell is not unfre- 
quently observed, and is a wide departure from the ordinary plan of 
healthy cell-growth. Fibres are formed partly by development from 
nuclei, which are often seen elongated, partly, and in greater degree, 
from the blastema, by splitting up and division ; they are rarely as 
perfect as those of healthy tissue. An albuminous fluid, in varying 
quantity, is diffused through a cancerous mass, and beyond all doubt 
partakes of the qualities of the solid structure; in it the bloodvessels 
may be said to lie bathed, and by it, in consequence, the blood travers- 
ing the organ must be contaminated. This same fluid is also taken up, 
in part, by the lymphatics, and thus readily communicates its own can- 
cerousness to the nearest lymphatic glands. The growth of a cancer- 
ous tumor will be more rapid, in proportion as its structure is mainly 
composed of cells, and contains but little fibre, and is also so situated 
that it has room to expand freely. Encephaloid, in which cell-structure 
always predominates, is, notoriously, of most rapid growth, but even 



CANCEROUS TUMORS. 209 

its progress is comparatively slow, while it is confined within unyielding 
walls, as in the globe of the eye. Laennec supposed that all cancers 
were originally hard, and that in the process of growth they gradually 
became softer ; this is not so ; cancers may be quite soft at their com- 
mencement; but still, they do generally appear to diminish in consist- 
ence as they advance in age. Tumors, however, of the same date may 
differ very greatly in consistence. Inflammation may affect cancerous 
tumors ; it is commonly excited by their exposure to the air after they 
have made their way through the covering parts. It powerfully ac- 
celerates softening and decay. Suppuration may take place as the 
result of inflammation, but the pus is an ill-formed sanious product, 
mingled with detritus. Cancerous formations sometimes mortify spon- 
taneously, sometimes in consequence of inflammation; in the first case 
a cure has been known to take place, and to attain this artificially is 
the object of various escharotic applications. It is evident that it is 
only in instances of cancer, whose powers of vegetation are feeble and 
sluggish, that such a proceeding can be successful. There are two 
other changes which cancer occasionally undergoes, and which may re- 
sult in a cure. One is that called Saponification, by Rokitansky, which, 
however, seems to be simply fatty degeneration. It is this change, in 
an early stage, which constitutes Carcinoma reticular e; it occurs with 
formation of granule cells, or independently of them. The other 
change is a shrinking and contraction, a kind of drying up of the can- 
cerous growth with deposition of calcareous matter, analogous to cretifi- 
cation of tubercle. 

The term primary is applied to cancerous growths, originating for the 
first time in the system, secondary to those that are in some way derived 
by dissemination from the primary. We have already alluded to one mode 
by which secondary cancers are established, viz: that through the medium 
of the lymphatics; and we have stated that it is the cancerous blastema 
which is absorbed, and which gives the impulse to cancerous develop- 
ment in the glands. This, there can be no doubt, is equally capable of 
propagating the infection as any solid germs to which it is in fact equi- 
valent. If in some instances it does not do so, it is because the natural 
assimilative power of the gland tissue resists the infectious tendency of 
the blastema, and perseveres in its own normal mode of nutrition and 
action. In the same way, we believe that the bloodvessels traversing 
the cancerous mass readily imbibe through their delicate parietes the 
diffused blastema, and that the blood thus contaminated, when it arrives 
in a suitable nidus, deposits there a blastema, which, under favoring 
circumstances, gives rise to a secondary tumor. The nidus is most often 
the next capillary plexus at which the blood arrives ; thus, cancer of the 
breast occasions cancerous tumors in the lungs in almost all cases in 
which it also affects the liver, but it often produces cancer in the lungs 
without any occurring in the liver ; cancer originating in the stomach 
occasions similar disease in the liver to which its veins proceed, before 
it produces any in the lungs. It is easy to understand that a suitable 
nidus is requisite, and that, if the organ first traversed by the blood pro- 
ceeding from the infected part does not afford such, the material will be 
effused in vain, the seed will not germinate in a soil unsuited to it. The 
14 



210 CANCEROUS TUMORS. 

recognition of the efficiency of cancerous blastema to produce similar 
formations is of some importance, as it does away with the difficulty of 
supposing that solid germs are introduced into the circulation through 
some breach in the walls of the vessels. These may, doubtless, some- 
times make their way into the blood, but there is no proof that they do ; 
and we are certain, on mere physical grounds, that the blastema must. 
The analogy of pyaemia is in favor of our views ; Lebert has shown that 
the serum of pus produced like effects to the entire fluid, and that the 
globules of pus were not the special cause of the multiple abscesses by 
being arrested in the capillaries, as they were soon destroyed in the 
blood. Cancerous blastema, or germs, may be communicated also in 
another way, viz : by actual contact of the diseased with other parts ; 
cases are mentioned by Dr. Budd, and Mr. Simon, which may be con- 
sidered to prove this, though there is no improbability whatever in it. 
Fluid blastema might easily be imbibed from a growth by a soft tissue in 
frequent contact with it, just as a solution of some salt would be. Germs, 
that is, nuclei and cells, might also be similarly transferred, if any 
breach of surface in the growth had occurred. Pathologists are gene- 
rally agreed in attaching little credit to the results of the experiments 
which have been made relative to the production of cancer by inocula- 
tion, or injection of the cancerous matter. Some few are said to have 
succeeded, but the great majority have failed ; in this there is nothing 
surprising ; we quite agree with Dr. Walshe, that the non-production of 
cancer by inoculation proves conclusively "the absolute necessity of 
constitutional predisposition" for the development of the disease. A 
healthy system will resist and overcome by an assimilative force the 
cancerous poison, just as it will in the case of a dog that of pus, while a 
weaker system might be infected by it, as the rabbit is by the injection 
of pus. What has been called the metastasis of cancerous tumors has 
occasionally been observed ; see a case quoted by Dr. Walshe, p. 110, 
from Recamier ; in this, it must not be supposed that the tumor existing 
in one part is removed molecule by molecule to another, but that either 
a small pre-existing tumor was excited to rapid growth by the wasting 
and absorption of the other, or that absorption being induced by some 
local condition, blastema, or germs, were carried in the circulation to 
the new nidus, where they commenced to germinate and develop afresh. 
Were such cases of transfer frequent, they would constitute a considera- 
ble objection to the plan of causing absorption of a tumor by pressure 
upon it. It might be reasonably conceived that the structure of the 
locality in which cancerous blastema was deposited, would influence the 
kind of tumor that was therein developed, and such does appear to be 
the case, at least to some extent. Thus scirrhus is far more common 
than encephaloid in the female breast, which abounds in fibrous tissue ; 
and encephaloid is most frequent in the liver, which contains little of it, 
and chiefly consists of cells ; the muscular walls of the stomach are 
commonly also affected by scirrhus, as well as those of the uterus, and 
both these consist mainly of fibres. On the other hand, there are excep- 
tions in the case of the lungs, and of the meninges w T hich are most often 
attacked by encephaloid. The species of cancer termed epithelial, 
seems certainly to be determined by the peculiarity of its site, as it 



CANCEROUS TUMORS. 211 

seems almost invariably to be developed on free cell-bearing surfaces. 
It is generally true that the greater the proportion of fibre in a tumor, 
the less is its malignancy ; especially intending thereby its tendency to 
contaminate the system, and to destructive ulceration. On the other 
hand, the more it abounds in cell-growth, and in fluid blastema, the 
greater is its malignant capacity. M. Simon says, "in proportion as 
the blastema has suffered itself to undergo a fibrous transformation, in 
such measure I cease to recognize that which is distinctively cancerous 
and malignant." Believing this to be in great part true, we must still 
remember that the abolition of a truly scirrhous growth may be followed 
by the development of encephaloid ; the inactive fibroid structure is still 
the expression of the comparatively quiescent constitutional infirmity, 
which may at any time be roused to its more severe manifestations. 
There is much probability in the common opinion, that cancer is an 
hereditary disease. Dr. Walshe acknowledges his belief in the disease 
having thus originated in some cases which he witnessed; and, indeed, 
most persons might adduce confirmative testimony. Still, actual statisti- 
cal proof has not yet been afforded. Cancer is, on the whole, a disease 
of advancing age ; it does, indeed, exist occasionally at every period of 
life ; both scirrhus and encephaloid have been observed in the foetus, 
and encephaloid is not uncommonly seen in infants and children of ten- 
der years ; but the researches of Dr. Walshe show that the mortality 
from cancer " goes on steadily increasing with each succeeding decade 
until the eightieth year," so that, taking the mean of both sexes, it 
attains its maximum between the ages of seventy and eighty. In males 
the ratio of increase is more uniform than in females ; in them, there is 
a great and rapid increase of mortality between the ages of thirty and 
fifty, which "lends support to the current belief respecting the con- 
nection of the development of uterine and mammary cancer with declin- 
ing activity and cessation of the genital functions." The influence of 
sex upon the development of cancer is very striking; Dr. Walshe's 
tables show that in six years an absolute number of deaths from this 
disease, in males, was only 3495, compared with 10,146 in females, al- 
though the mean rate of mortality in the male exceeds that in the female. 
A sanguineous temperament is considered, by several who have paid at- 
tention to the question, to predispose in some measure to cancer. More 
powerful are the effects of mental distress, and of the refining, but ener- 
vating influences of civilized life ; at least, such are the conclusions to 
which the evidence that can be obtained at present seems to point. A 
fact of a rather opposite import which Dr. Walshe establishes, is that a 
town life has no greater influence than a country one, in promoting the 
development of cancer ; in fact, a greater number die of cancer in the 
country, than in the towns; this applies to the mean of both sexes, but 
taking the females separately, the mortality from cancer among them 
is greater in the town than in the country. 

An injury to a part (the observation is most common in the case of 
mammary cancer) seems to be often the exciting cause of cancerous 
development, and it is probable enough, and accordant with the analogy 
of growth, that a weakened part should offer the least resistance to the 
localization of constitutional disease. However, the immunity from can- 



212 CANCEROUS TUMORS. 

cer observed in the Parisian prostitutes, and the result obtained by 
Andral, with regard to cerebral carcinoma, as following injury, show 
that but little is to be attributed to this as an exciting cause. Habitual 
irritation of the stomach by alcoholic liquors has no effect in inducing 
carcinomatous disease of this organ, though it may have sometimes pro- 
duced a state of simple induration, which has been mistaken for scirrhus. 
It is, however, not to be denied, that irritation may in some cases de- 
termine the formation of a cancer; as, for instance, in the scrotal cancer 
of chimney-sweeps, which certainly seems to be called into existence 
from a latent predisposition by the irritation of soot. 

In concluding this subject, we may offer a few remarks with reference 
to the effects of removing cancerous tumors by operation. In the first 
place, it is quite clear that the disease is manifestly constitutional, and 
that no sound, real cure can be expected from merely removing its ex- 
ternal development. Secondly, it is matter of experience, that in not 
a few instances surgical interference with one tumor has provoked the 
speedy appearance of several others. Thirdly, any attempt at removal 
is useless; nay, may be absolutely injurious, unless every particle of 
cancerous structure is taken away. Fourthly, epithelial cancers seem 
least prone to return after removal; encephaloid invariably does, and 
mostly with great rapidity ; scirrhus may be checked in its progress, but 
its return can very rarely be prevented. The check which may be given 
by operation to the progress of cancer depends on the circumstance 
before stated, that a tumor, once formed, becomes an instrument for the 
multiplication of similar tumors and intensification of the diathesis. It 
must require a combination of favorable circumstances, or a great in- 
tensity of the diathesis, to insure the development of effused blastema 
into an heterologous growth; but when this has taken place, then the 
very growth and vital actions of the structure will constantly generate 
fresh supplies of cancerous blastema, and thus promote the formation of 
secondary cancers. The destruction, therefore, of the growth, which 
thus reacts so evilly upon the system, may be reasonably expected, if 
it do not aggravate, to delay the cause of the disease. But the misfortune 
is, that, as above stated, it does sometimes aggravate, and that fearfully, 
a previously indolent cancerous diathesis. Dr. Walshe says, "excision 
of a tumor seems to awaken a dormant force, cancers spring up in all 
directions, and enlarge with a power of vegetation almost incredible." 
Why this should happen, we do not know ; but we may conjecture that 
when the original diathesis is slight, the formation of a tumor may tend 
in some degree to localize it, and leave the system in a somewhat healthier 
state, provided the tumor itself be chiefly fibrous, and produce but a 
small amount of blastema. The removal of the indolent tumor may be 
analogous to the cure of fistula in ano in a person of phthisical tendency. 
The two principles referred to of the cancerous tumor, in one case acting 
as a cause, increasing the force of the disease, and in another retarding 
it, are not contradictory, though opposite; they will prevail in different 
degrees in different instances, according to the kind of tumor and other 
circumstances. 



CHAPTER V. 

Foreign bodies of very various kinds are not uncommonly found in 
the living organism, having made their way in through the natural 
orifices, or having been introduced through wounds. They often occa- 
sion a great deal of irritation, excite inflammation and suppuration, and 
in this way become eliminated. At other times, they remain for years 
without producing any symptoms, and are only discovered after death. 
When this is the case, they are generally inclosed in a fibroid cyst, 
which isolates them from the adjacent textures, and prevents them 
causing irritation. We recently found a bullet thus capsulated in the 
abdomen of a cat, close to the left kidney; the animal was in per- 
fect health. Dr. Walshe quotes a case in which an ounce of arseni- 
ous acid was swallowed without producing any fatal effects ; after the 
lapse of a year the suicidal attempt was repeated, and with success. 
The arsenious acid of the former attempt was found inclosed in a 
cyst, which had evidently prevented it from exerting its poisonous 
influence. 



PARASITES. 

These are organized formations existing in a living organism, but not 
connected with it by any continuity of tissue, and possessed of an in- 
dependent life. In these respects they differ from the class of new 
formations. They have been often supposed to be produced in a spon- 
taneous manner, originating as by a kind of necessity from morbid 
products; but the progress of inquiry has proved, almost completely, 
that this is not the case; that they are developed from sporules or ova, 
just as beings of a higher rank are; and that the cause of their appear- 
ing in certain localities, under certain morbid conditions, is, that in 
such cases the germs find a suitable soil or nidus wherein they can be 
developed. We believe that recent researches have also rendered it 
very probable, if not certain, that the same species of parasite may 
develop itself very differently in different localities ; so that some, which 
were formerly regarded as distinct species, are now considered to be 
only varieties of the same. 

Vegetable Parasites. These are microscopic growths belonging to 
the lowest class of the vegetable kingdom. They are found most com- 
monly on diseased mucous surfaces, sometimes in exudations, but it 
cannot always be clearly determined whether they are the cause of the 
diseased state, or whether (as is more probable) the diseased tissue has 




214 PARASITES. 

merely afforded a suitable nidus for their development. We enumerate 
those which have been observed, after Rokitansky, as follows: (1.) The 
mycoderm of favus. It consists of minute, transparent, round or oval 
vesicles, often united in branching threads. This arrangement results 
from their mode of growth by elongation and division of the cells. 
M. Lebert has observed a rotary movement of the 
109 - separate or united cells similar to that which has 

been detected in other cryptogamia. The vegetable 
growth is inclosed in a kind of capsule, which is 
marked on the surface by a funnel-shaped depres- 
sion, and is of a sub-conical shape beneath, where 
it is implanted in the skin. Experiments to repro- 

Drawing of Mycoderm of duce ^ diseage by i n0 Culatioil with the mycodermic 
Favus — partly from Le- 1 * -i i • 

bert . sporules nave scarcely ever succeeded; it seems 

therefore probable that they do not constitute the 
essence of the disease. (2.) A similar fungous growth has been found 
in the sheath surrounding the root of the hair in sycosis. (3.) In 
porrigo decalvans, a growth of very minute fungi has been detected 
within the roots of the hairs. (4.) A similar one has been found in 
the hair roots in plica polonica. (5.) Also, in pityriasis versicolor. 
Croupous, aphthous, and diphtheritic exudations upon the mucous surface 
of the mouth, pharynx, oesophagus, intestine, and larynx, are often 
found to contain minute fungi very similar to those of favus, except 
that they are longer and more slender, and more distended by reproduc- 
tive granules at their terminal extremities. They have also been ob- 
served in gangraena oris, in sputa from a patient affected with pneumo- 
thorax, in the sordes of the teeth, &c. 

Animal Parasites. Infusoria (vibriones and vorticellse) are not un- 
frequently found in pus, and probably in other fluids. Dr. Bence Jones 
has discovered vibriones in the urine of a child the moment after it was 
passed. The following insects are known as human parasites: the 
common flea (pulex irritans), the chigoe of the West Indies (pulex 
penetrans); the pediculus capitis; the p. pubis; p. vestimenti; p. tabe- 
scentium; the common bug (ciraex lectularius). To these may be added 
the harvest bug, which, like the chigoe, burrows into the skin probably 
for the purpose of laying her eggs. Among arachnida, we find two 
species of acari, that frequent, the one the epidermis, and the other the 
sebaceous follicles. The acarus scabiei (sarcoptes hominis) is a minute 
whitish creature, about T J^ — -g 1 ^ in. in size ; it has no true head, but is 
provided anteriorly with proboscis-like mandibular organs furnished 
with four bristles. There are eight legs, " four anterior are inserted 
into the thorax by the side of the proboscis, are jointed, and furnished 
with hairs and bristles, the last joint of each terminating in an adherent 
disk. The posterior legs, without adhering disks, terminate in very 
long bristles." (Vogel.) The animal burrows in the epidermis, and 
forms minute channels, at the end of which it may often be discovered ; 
it does not inhabit the vesicles or pustules which constitute the erup- 
tion, and are simply excited by the irritative proceedings of the acarus. 
The acarus folliculorum is proportionally much longer, about ^ii — ih 
in. long. 5J5 in. broad; its head has two lateral palpse with an inter- 



PARASITES. 215 

vening proboscis ; its thorax is supported by four pairs of very short 
legs with terminal claws ; its long abdomen gradually diminishes to the 
end, and contains some granular matter and oil-vesicles. It inhabits 
the hair follicles and sebaceous glands in any region of the skin, where 
it may be found in the healthiest persons. It does not appear to excite 
any disease. The following Helminthic parasites infect man : (1.) Fila- 
ria medinensis, the Guinea worm, from six inches to twelve feet long, 
about as thick as a piece of packthread. It makes its way into the 
subcutaneous tissue of the lower limbs and some other parts, where it 
remains a variable time without exciting any particular symptoms; but 
when its progeny are approaching the period for their extrusion, it 
makes its way out, or is extracted by hand. The symptoms of this 
period are sometimes slight, sometimes very severe. If ruptured during 
extraction, the young escape into the cellular texture and excite an 
unhealthy suppuration. (2.) Filaria oculi humani, discovered in the 
surrounding fluid and in the crystalline lens. (3.) Filaria bronchialis, 
once found in diseased bronchial glands. Other filaria have been 
found in the blood and in the urine (spiroptera hominis, dactylius 
aculeatus). (4.) Trichina spiralis is a minute round worm, ^ to 
•g 1 ^ inch long, with an intestinal canal and distinct oral and anal 
openings. It occurs inclosed in a transparent cyst, which is situate 
in the interior of the fibres of voluntary muscle, separated by the 
sarcolemma from all surrounding textures. Sometimes there are two 
or three worms in one cyst. Sometimes the cyst contains calcareous 
matter, in which case the worm is most commonly dead. The patholo- 
gical significance of this worm is not very apparent; it has often been 
found in persons who have died of different diseases, and even in those 
who perished while in health and vigor. (5.) Tricocephalus dispar, a 
thin filiform worm, one and a half to two inches in length. Its anterior 
two-thirds are quite capillary, and pass rather suddenly into the thicker 
posterior portion. The sexes are distinct ; the male has a long penis 
invested with a proper sheath. The female produces numerous ova, few 
of which are probably developed. The worm is found chiefly in the 
coecum, adhering by its head to the mucous membrane; it is sometimes 
solitary, sometimes occurs in great numbers ; it does not appear to pro- 
duce any remarkable symptoms. (6.) Ascaris lumhricoides, a round 
worm, pointed at both ends, from six to fifteen inches long, of a grayish 
and sometimes red color, sufficiently translucent to allow the viscera to 
be seen, marked by two lateral lines corresponding to the principal 
vessels, and by two others less distinct, and corresponding to the 
nervous cords on the dorsal and ventral surface. The head is sepa- 
rated from the body by a slight constriction ; at its extremity is the 
mouth, surrounded by three tubercles. The anus is situated on the 
under surface, near the extremity of the tail. The reproductive organs 
consist, in the male, of a single seminal tube, three feet long, terminat- 
ing in a reservoir about an inch in length, which communicates with the 
base of the penis: in the female, they comprise the vulva, situated at the 
junction of the anterior and middle thirds of the body; a vagina, five or 
six lines long; a uterus, which divides into two long, tortuous oviducts, 
gradually diminishing to capillary ovarian tubes, which are conspicuous 



216 PARASITES. 

by their whiteness, as they are coiled around the intestinal canal. They 
inhabit chiefly the small intestines, but roam about occasionally up into 
the gall-ducts, the stomach, the oesophagus, and have even made their 
way into the nostrils and into the mouth, as happened in a girl under 
our care. It seems at least doubtful whether they ever perforate the 
coats of the intestine and get into the peritoneum. Sometimes they are 
very numerous; one patient passed as many as four hundred and sixty 
in a fortnight, but this is not common; however, one would rather be 
inclined to expect, from the appearance of one, that there were others 
remaining behind. They have been known to accumulate so as to ob- 
struct the intestines; more commonly, they produce only some amount 
of irritation, or even no symptoms at all. We think we have seen a 
case of convulsive paroxysms depending on the presence of these para- 
sites in the bowels. (7.) Ascaris vermieularis ; a minute, white, thread- 
like worm, of separate sexes ; the male about one and a half lines in length, 
the female five or six ; the former has a spirally coiled tail, the latter a 
straight, tapering, and very delicate one. There is a transparent tube- 
rosity on the head, with a kind of alar membrane on each side. They 
inhabit the rectum in vast numbers, and may crawl out and get, in females, 
into the orifices of the adjacent canals. They occasion very distressing 
irritation, perhaps in consequence of their restless disposition, which has 
obtained for them their name of ascarides (asxapi^ «/, to leap). (8.) Stron- 
gylas gigas, a formidable large round worm, which attains sometimes 
three feet in length, and is of a blood-red color. The male, as usual, 
is the smaller, is marked by circular striae and " shallow longitudinal 
furrows;" at its posterior extremity it has a funnel-shaped pouch, from 
which a slender penis protrudes. The female has a straighter and more 
obtuse tail, and at one or two inches' distance from it the vulva. It in- 
habits the kidneys, and causes more or less destruction of this organ. 
Among the trematoda, we are acquainted with three species of distoma, 
which have been found, though rarely, in the human subject. The d. 
hepaticum and d. lanceolatum are both flat, lancet-shaped worms, of a 
yellow-white color, with two suckers, one of which situated at the head 
forms the mouth; the other is on the abdomen, and is imperforate. The 
orifice of the sexual organs lies between these two. They are herma- 
phrodite. The d. hepaticum is the larger, being eight to fourteen lines 
in length, and from one and three quarters to six lines in breadth ; its 
intestinal canal is ramified. The d. lanceolatum is only two to four lines 
long and one broad; its intestine is bifurcated. They have been found 
in the gall-bladder and ducts, and in the v. portse and its branches. 
Distoma oculi humani is of minute size, and has been found in the fluid 
surrounding a cataractous lens. Cestoidea. — Two very common para- 
sites of the human subject belong to this order, the taenia solium and 
the taenia lata. They are both flat-jointed worms, of a whitish-gray 
color, and attain, very often, an immense length. Their joints, laden 
with ova, frequently separate, and are discharged from the system, 
while fresh ones are formed in succession behind the head. The one 
do not appear to be developed in the organism inhabited by the parent 
worm. The head of the taenia solium is at the anterior smallest 
part of the worm; it is provided with four lateral suckers, between 



PAKASITES. 



217 



which is a circle, sometimes supporting a double row of hooks ; in the 
centre of this circle there is a minute opening, that of the mouth. " The 
anterior segments," Professor Owen says, "are feebly represented by 
transverse rugae ; the succeeding ones are subquadrate, and as broad as 
long." Advancing posteriorly, the segments still increase in length and 
size ; the anterior part of each is overlapped by the broader posterior 



Fig. 110. 



FWjM 






Taenia solium. Head and joints. 



Taenia lata. a. Marks the generative orifices in both. 
From Owen's Lectures. 



part of the preceding. At about the middle of the margins of the joints 
is situate the orifice of the generative canals, which is in successive joints 
on alternate sides; this constitutes a distinction between the taenia solium 
and the taenia lata, in which the genital orifices are in the middle of the 
ventral surface of the segments. The alimentary canal in both taeniae 
seems to commence as a single minute tube, which soon bifurcates and 
forms two divisions, which run throughout the length of the worm, at a 
little distance from the margins. The generative apparatus is very highly 
developed in each joint, consisting of a large branched ovarium and a 
seminal tube, which terminates as a small rudimental penis, situated just 
anterior to the opening of the ovarian canal. The head of the taenia lata, 
or Bothriocephalus latus, forms an elongated, sub-compressed enlarge- 
ment, with an anterior obtuse prominence, perforated by the mouth, and 
having two lateral sub-transparent parts separated by an opaque tract; 
these have been regarded as depressions (/3o0pia), whence the generic 
name. There is no trace of joints within 2 J inches of the head ; these 
are, at first, feebly marked, then the segments expand posteriorly, and 
slightly overlap the succeeding ones; their length nearly equals their 
breadth. The generative apparatus repeated in each segment, as in the 
taenia solium, is still more developed, and occupies, especially in the 
hinder segments, by far the greatest part of the space. It consists of 
complicated tubular ovaries, and a convoluted uterus, on the one hand; 
and of a large glandular testis, vas deferens, seminal receptacle, and 
penis, on the other. Certain glands, which seem to furnish a matter 



218 PARASITES. 

to protect and cement together the ova, open into the uterus, near its 
termination at the vulva. The multiplication of the joints seems to 
take place by division of the first, that immediately succeeding to the 
head, the two parts subsequently enlarging. The substance of the 
joints in the taeniae consists of very minute nucleated cells, which doubt- 
less obtain nutrition by absorption of chyle through the delicate integu- 
ment. There are two layers of muscular fibres, a transverse and longi- 
tudinal. The ova are most matured in the posterior segments, which 
are, of course, the oldest. It is extremely remarkable, and a most mer- 
ciful provision, that the ova do not undergo development in the intestine 
which lodges the parent; otherwise, their enormous multitude would 
speedily exhaust the individual infested by them. The further progress 
of the ova has not been determined, but it is most probable that after 
extrusion they (that is, such as do not become abortive) light upon some 
suitable nidus, where they attain a certain stage of development before 
they are again transferred to the intestine of some hospitable recipient. 
The taenia solium is a native of Britain, Holland, Germany, Egypt, and 
the Levant; the taenia lata, 'of Russia, Poland, Switzerland, and East- 
ern Prussia, and of Middle and Southern France : it is clear that it is 
some peculiarity in the localities, and not in the human inhabitants, 
which determines this limitation, as a visitor to a foreign country may 
be attacked by a different parasite to that which is indigenous in his 
own land. Cystica. — There seems to be good reason to doubt whether 
the animals contained in this order should be separated from the pre- 
ceding; the formation of the head in both is identical, or nearly so, and 
the different shape of the body may very possibly depend on its being 
placed under different conditions of development. Cysticercus cellulosa 
has a conical, glistening, white, transversely wrinkled body, and a cau- 
date vesicle, which assumes various shapes, according to the pressure of 
surrounding parts. Its size is about that of a pea or bean, in most 
cases, but when situate in open cavities, as the cerebral ventricles, it 
may attain the size of a hazel-nut. The body and head can be drawn 
into the vesicle, and when there may escape notice. The head is some- 
what larger than the neck, of a quadrangular shape, with a round sucker 
at each angle, and provided in the middle, at the base of a conical 
proboscis, with a double circle of hooks, amounting in number to about 
thirty-two. In structure, the body and globose tail consist of a well- 
marked homogeneous membrane, which is covered over internally with 
a layer of highly-refracting celloid particles. These are very closely 
packed together in the body, but are less numerous in the neck, and 
disappear by the caudal appendage; they have very much the aspect of 
fat- cells, but are shown, by the action of acid, to contain carbonate of 
lime. They lie upon a stratum of dark, finely-divided molecular matter, 
which is also spread over the surface of the interior of the caudal pouch. 
A neutral, slightly albuminous fluid distends this cavity moderately. 
When the cysticercus lies in the substance of an organ, it determines 
the formation of a kind of fibrous cyst around itself; this is wanting 
when it lies in a natural cavity, as the ventricles of the brain. After 
the death of the animal the body collapses, and degenerates, more or 
less completely, while calcareous deposition at the same time takes 



PAKASITES. 



219 



place, so that there remains at last only a chalky mass surrounded by a 
fibrous cyst. This parasite occurs in the brain, and in the voluntary 
muscles; it is sometimes solitary, sometimes in great numbers. Echi- 
nococcus hominis is a minute, but very interesting and not uncommon 
parasite, which inhabits, in great numbers, the interior of those large 
globular sacs which are called acephalocysts or hydatids. One of these 
consists of an external enveloping cyst, composed of condensed fibrous 
tissue closely in contact with the tissue of the part in which it lies, 
traversed by some vessels, and lined on its interior, according to Yogel, 
by an epithelium. Within this is a second cyst of nearly milk-white 
aspect, nearly brittle, and yet, elastic in some degree, without any 
organic connection whatever with the inclosing cyst, and filled, itself, 
with a pellucid serous fluid, in which are often numerous secondary cysts, 
either free and floating, or attached to the wall of the parent. These 
secondary cysts sometimes contain a tertiary, and the tertiary again a 
fourth generation. The younger cysts are tensely filled with a fluid like 
that of the parent, which spurts out on an incision being made, while 
the membrane curls outwards. They are sometimes so numerous as to 

Fig. 112. 




A. Echinococcus, the head retracted. 

b. Echinococcus, the head and cornet of hooks facing the ohserver. 

c. Echinococcus, the head extruded. 

D. Section of wall of acephalocyst, with blastematous layer, in which are seen several Echinococci. 



occupy great part of the parental cavity ; they vary, also, much in size, 
from that of a small seed to that of a goose's egg, or even more. Their 
membrane is precisely similar to that of the parent; it is beautifully 
seen, when a thin vertical section is placed in the field of the microscope, 
to consist of a very great number of laminae, which are arranged con- 
centrically, and vary in thickness, from 5^00 — 2 0*0 "5 inch, according to 
a recent observation which we made. The substance of the membrane 
has the chemical properties of coagulated albumen, or fibrin, and there 
can be no doubt that it is the result of the effusion of liquor sanguinis 
from the external cyst, which solidifies as it is effused, layer by layer ; 



220 PARASITES. 

and thus, somewhat after the fashion of an aneurismal sac, is formed 
an interior laminated cyst. But little is known as to the mode of form- 
ation of the secondary cysts; what we have ourselves observed amounts 
to this: On the interior of a primary cyst, a number of whitish opaque 
spots, of the size of a pin's head, were seen; these were produced by 
the existence of a number of circularly disposed laminae, identical with 
those of the membrane itself, and apparently inclosing a cavity. A 
little more elevation and isolation of these spots would have produced 
a secondary cyst ; not indeed detached, but sessile, as they often are 
found to be. The transparent fluid contents of the cysts have a specific 
gravity of 1.008 — 1.013, are neutral, or slightly alkaline, contain very 
little albumen, if any, some extractive and fatty matter, and some salts, 
especially chloride of sodium. With respect to the echinococci, whose 
habitation we have now described, they seem to form in a stratum 
which lies on the inner surface of the parent cyst. This is of opaque 
oily aspect, and consists of imperfect celloid particles, irregularly shaped, 
non-nucleated, a little larger than pus-corpuscles, and with faint granu- 
lar contents, lying imbedded in an oily and granular matter. In this 
kind of blastema there lie numerous echinococci, which, as in the in- 
stance referred to, may be separated, or aggregated together in groups. 
The groups are sometimes inclosed in a spherical sac, attached by a 
pedicle to the wall, or the individuals of the group are connected to- 
gether only by a short branching pedicle, which sends a division to 
each. The echinococci are about 53 -g in. — ^\ in. long, and 3 Jq — 
t 1q in. wide; they have a head much like that of a taenia, provided 
with four lateral suckers, and a double row of hooklets, situate at the 
extremity, around an orifice. The head is separated by a contraction 
from a thicker roundish body, at the posterior extremity of w r hich is a 
transverse depression, into which a short delicate pedicle is inserted. 
This pedicle is the same before mentioned by which the animal is at- 
tached to the cyst membrane. The echinococcus is most commonly 
seen with its head inverted, and, as it were, doubled inwards, so that 
the animal appears of an oval shape, with an orifice at the part oppo- 
site to the attachment of the pedicle, and a narrow canal leading from 
thence downward to the middle of the interior, w T here the circlet of 
hooks is now seen marking the position of the extremity of the head. 
It consists of a strong, homogeneous membrane, which is covered over, 
internally, by a soft granulous substance, in which are imbedded several 
refracting, probably calcareous, celloid corpuscles. There is no appear- 
ance of reproductive organs in the echinococci; the young seem to be 
produced in the blastematous layer we have already noticed. They are 
described by Mr. Erasmus Wilson as originating in certain transparent 
cells, some of which are, however, more opaque. Both contain smaller 
cells, but these are more defined in the latter, and are mostly nucleated. 
The inclosing membrane of the primary cell ruptures, and the included 
cells are diffused " in the form of a small opaque patch in the substance 
of the internal membrane of the acephalocyst." The cells multiply, 
and form a small globular prominence on the surface of the membrane, 
while one larger and more transparent cell is to be seen in the interior 
of the mass. As the germinal patch increases in size, other protrusions 



PARASITES. 221 

take place around the base of the original one, and develop in the same 
way. The formation of the echinococcus from the mass of cells seems 
to take place by their coalescence, and retiring from the centre so as to 
leave a tubular canal, which Mr. Wilson believes to be modified, so as 
to form in the body the retractor muscle of the head, and exterior to it 
the peduncle. 

A ciliary movement has been seen by M. Lebert in the interior of echi- 
nococci; it does not, however, appear to be a constant phenomenon. We 
have never seen it ourselves. Among the multitudes of living echinococci, 
some are found which are shrivelled, altered in shape, more opaque than 
the others, and filled with an opaque granular mass. These are doubt- 
less dead, and, at the same time, traces of others, which have completely 
decayed, are discernible in the shape of detached hooklets. When, as 
occasionally happens, a cyst, such as we have above described, is entirely 
barren of echinococci, it is properly termed an acephalocyst. This is 
much more frequently, we think, the case with the secondary and ter- 
tiary than with the primary cyst. We cannot hesitate for a moment to 
regard the cyst productions as simply results of a peculiar exudative 
process, and not as in the least partaking of the character of animals. 
The exterior envelop is derived from the natural tissues of the affected 
part; the interior, which can alone be considered as proper to the ace- 
phalocyst, can scarcely be said to be organized, not, we think, certainly 
so much as the successive layers of false membrane, which are formed 
upon an inflamed serous surface. Neither can we consider the acephalo- 
cyst as a " gigantic organic cell," as all we know of its origin is entirely 
opposed to such an idea. Its relation to the echinococci is, in all proba- 
bility, that of affording a suitable nidus for their formation and develop- 
ment; but it is by no means clear why, in some acephalocysts, the animal 
cells are wanting; or why, in others inhabited by them, no secondary 
cysts are produced. Perhaps it may be found that the development of 
echinococci and secondary cysts takes place in an inverse ratio to each 
other. The cysts, both primary and secondary, are subject to degene- 
rate ; they become less tensely filled, their walls softer and more gelatin- 
ous, their contents turbid with diffused granulous matter and debris of 
echinococci. At last they shrivel up into a caseous mass, which is often 
the seat of calcareous deposit. A variable number of its progeny may 
decay in this manner, without the parent cyst itself being similarly 
affected. Inflammation of the external enveloping cyst is the chief 
cause of the destruction of the primary formation in contact with it ; 
this is sometimes very acute, and leads to the formation of an abscess, 
which subsequently opens externally, or into some of the adjacent cavi- 
ties or canals. The debris of the acephalocyst and its contents may 
be evacuated in this way, and as the cavity contracts and closes a cure 
is effected. When the inflammation is more chronic, the exudation which 
is poured out into the cavity of the primary cyst seems to derange the 
nutrition of the included ones, so that they shrink up and degenerate 
into mere laminae, of cheesy consistence; these, together with an oily 
calcareous residue of the fluid contents, which are gradually absorbed, 
remain in the interior of the primary cyst, which itself wastes and 
shrinks like its included progeny. In this way, another kind of cure of 



222 PARASITES. 

the disease takes place, as the degenerated mass may remain for an in- 
definite time in the substance of a part, without giving rise to any symp- 
toms. Such degenerated acephalocysts have, it would appear, been 
mistaken for tubercle. The following organs are occasionally the seat 
of acephalocysts. The liver, xat 1 sio^v, the peritoneum, and the under- 
lying areolar tissue, the muscles, the brain, the spleen, the kidneys, the 
lungs, the bones. They not uncommonly occur in several parts at the 
same time. The only injurious effects ordinarily caused by acephalo- 
cysts, are such as result from pressure on important parts. It may, 
perhaps, happen that they cause exhaustion when very numerous. 

It may be well to add a caution, with respect to Pseudo-parasites, as 
they are termed. These are either real animals, which are mingled 
with the excretions by impostors, or substances which are really produced 
in the body, but are not animals at all. It may sometimes require a 
more than ordinary acquaintance with parasitic animals to arrive at the 
truth. 



THE PATHOLOGICAL ANATOMY -OF THE 
NERVOUS SYSTEM. 



CHAPTER VI. 

GENERAL OBSERVATIONS. 

In no organ or system of the human body is there such an apparent 
want of accordance and definite relation between the symptoms of dis- 
ease and the structural derangements and changes produced by it, as in 
the nervous system at large. This is due to various causes. In the 
first place, our physiological knowledge of the laws governing the action 
of the nervous system is not on a par with our acquaintance with the 
processes operating in other organs ; chemistry, physics, mechanics, 
can be called to aid in the investigation of the healthy and diseased 
states of the bones, the soft tissues investing them, the thoracic or ab- 
dominal viscera ; and the structure of these parts is more analogous to 
what meets the eye of the scientific observer in other departments of 
nature. The only agent to which nervous functions can be compared, 
eludes our senses, except in its manifestations, as much as the opera- 
tions of the cerebro-spinal energies themselves ; we can judge of gal- 
vanism and electricity by the effects they produce, but we do not see 
their modus operandi ; and we have not even succeeded in demonstrat- 
ing, as yet, the existence, in the brain or spinal cord, of a structure 
which may legitimately be concluded to generate a force, in a manner 
similar to the production of that powerful agent, which is now meta- 
morphosing the human race. It, is, then, manifestly impossible, if we 
are imperfectly acquainted with the laws governing the nervous system 
in health, that we should be able, sufficiently, to define and appreciate 
the deviations from the healthy standard ; and, in many instances, we 
must be satisfied to refer for explanation of the symptoms we meet with, 
to hypothetical analogies, or confess our entire incapability of account- 
ing for the phenomena before us. A correct appreciation of the symp- 
toms of disease is a point which next may be fairly demanded of us, if 
we attempt to explain or seek for morbid phenomena after death ; 
thanks to Sir Charles Bell, Flourens, Marshall Hall, Romberg, and 
other distinguished inquirers of the present age, much has been cleared 
up, which previously appeared an impenetrable mystery ; but our means 
of physical diagnosis are still but scanty ; we are left, in a large num- 



224 GENERAL OBSERVATIONS. 

ber of cases, to form our opinions from the subjective statements of the 
patient; and where these fail us, as in early childhood, or in certain 
forms of disease, the greatest empirical experience may be inadequate 
to offer an explanation of the symptoms, or even to determine their 
exact relation to cerebral lesions. The peculiar connection of the brain 
with our mental powers and the soul, will, necessarily, ever place it in 
a different position, in regard to physical research, than other organs 
of the body, and in no department of natural science is the caution 
more necessary, that we should not mistake that which is unattainable 
to science, and that which the Creator has allowed to be within our 
reach; and, valuable as are vivisections, and other experiments, made 
upon the lower animals, in reference to neurology, we must never for- 
get, on the one hand, the disturbance to the ordinary laws of action 
likely to be produced by the injuries themselves ; and on the other, the 
chasm which intervenes between the brute creation and the human spe- 
cies. We cannot allude to the subject of the diagnosis of nervous dis- 
ease, without dwelling, forcibly, on the necessity for availing ourselves 
of those means which, limited as they may be, are yet not used as uni- 
formly and perseveringly as they are applied for the investigation of 
other morbid states of the body. A close examination by the eye and 
by the hand should be made of the cranium, the spinal column, and the 
courses of affected nerves ; the thermometer and the dynamometer 
should be brought into more frequent use, and more accurate tests of 
the sensibility and mobility, and other functions of the nervous system, 
ought to be employed than have hitherto generally prevailed. 

The researches of Bright, Frerichs, and others, have demonstrated 
the close relation of the state of the blood to cerebral disease; and 
science has shown, what, previously, was purely hypothetical, that 
the most fatal conditions may be thus induced without any palpable 
changes being wrought in the cerebral tissues. It does not, however, 
follow that, because we see no changes, none have taken place. The 
poison that we know to be in the blood may elude our chemical tests, 
and yet cause death. Then, seeing how limited our knowledge of the 
nervous system is, it is not to be wondered at that, although the mani- 
festation of altered function is so great as to force the belief in its 
altered constitution, it is not in our power to prove the latter to the 
perception; but, as Dr. Watson remarks, "whatever may be the nature 
of the unknown, and, perhaps, fugitive physical conditions of the nerv- 
ous centres, thus capable of disturbing, or abolishing their functions, 
it is useful to keep in our minds a distinct and clear conception of the 
fact, that there must be some such physical conditions." 

In examining the pathology of the nervous system, we shall adopt 
the succession usually followed by medical writers, and consider, first, 
the brain and its membranes ; next, the spinal cord, with its mem- 
branes ; third, the cerebro-spinal nerves, and the subject will be con- 
cluded by a summary of what is known with regard to the sympathetic. 



CHAPTER VII. 



THE DURA MATER. 



The intimate relation existing between the dura mater and the cra- 
nium renders it peculiarly prone to sympathetic affections propagated 
from the bone, and from its proximity to the latter it is most likely to 
be involved in injuries of a traumatic nature. As on its external sur- 
face the close contact with the cranium favors a communication of dis- 
ease from without, so the relation of its internal surface to the arachnoid 
induces a liability to communication of morbid action from within. The 
amount of idiopathic disease discoverable in the dura mater in the dead- 
house is not great ; though we are justified, by its character as a fibro- 
serous membrane, in assuming that it is frequently affected during life ; 
thus, the headaches complained of by patients affected with chronic 
rheumatism may often fairly be set down to a diseased condition of the 
dura mater, both from the resemblance which its symptoms offer to 
those occurring in rheumatism of other fibro-serous membranes, and 
from the success resulting from an anti-rheumatic treatment. It is not 
the general character of rheumatism to cause marked or extensive dis- 
organization when attacking membranous expansions, and there are no 
especial reasons to expect a deviation from this rule in regard to the 
fibrous covering of the brain. A considerable difference exists in the 
adhesion between the dura mater and the cranium at different periods 
of life, independently of disease ; the connection is lax in childhood, and 
is rendered more intimate and firm with advancing age, as the sutures 
become ossified and the bones lose their resiliency. It is especially in 
the latter period that external injuries are liable to implicate the dura 
mater as well as the bone, and one of the most common effects of blows 
or concussions is a forcible separation of the membrane, with hemor- 
rhage between it and the bone. The clot may, as elsewhere, be partially 
or entirely absorbed, and we accordingly meet with it in the various 
stages of metamorphosis. One form of hemorrhage in this region is 
connate, and is termed cephalhsematoma; 1 it is produced by the pres- 
sure exerted during parturition, and is generally found in the form of a 
tumor, varying in size from a Walnut to a child's head, on the parietal 
bone, presenting during labor. As this, however, is rather an affection 
of the pericranium, we shall revert to it when speaking of the morbid 
anatomy of the bones. We may state that nature adopts the same 
process of limitation and absorption in the case of the external as in the 
internal hemorrhage. 

1 Deriv. xe<j>aX», head; and alfAa.rwfA.x, sanguineous tumor. 

15 



226 THE DURA MATER. 

Inflammation of the dura mater presents the features of inflammatory 
action in fibrous tissues generally ; it is never of a very active character, 
and in many instances of contiguous inflammation, the membrane seems 
to act as a barrier, to intercept its progress. In the first stage the 
membrane presents a pinky hue, which is irregularly diffused, and evi- 
dently has but little tendency to spread. The injection causes the dura 
mater to assume a more lax and pulpy condition, and it is more readily 
detached from the adjacent parts. A stage of infiltration and suppura- 
tion, or of effusion of lymph may follow ; the latter is the more frequent 
result of idiopathic inflammation of the dura mater, and may give rise 
to induration, firm adhesion, thickening, or to new formations, such as 
the production of bone. In fibrous tissues generally the tendency to 
lymphatic effusion is rather on the surface, causing an attachment to 
adjacent parts, whether bone or muscle; in the dura mater, however, 
interstitial effusion is more frequently met with, on which account the 
latter is more likely to show the traces of inflammatory action than 
aponeurotic or fascial expansions. When apparent adhesions occur be- 
tween the dura mater and the arachnoid, which are not unfrequent, they 
are rather the effect of inflammatory action and deposition of lymph on 
the latter than on the former. In such a case' the removal of the dura 
mater cannot be effected without laceration of the arachnoid or the sub- 
jacent gray matter, or connecting bands or shreds are found to be drawn 
out as the membranes are separated. The reparation of solutions of 
continuity in the dura mater is not effected with the same rapidity and 
vigor that we see in more vascular tissues. From its contiguity to the 
skull it is very liable to be implicated in external injuries, which may 
assume the character of the injury to the bone, being cut, punctured, or 
bruised; or, we occasionally meet with laceration of the dura mater from 
concussion at a distance from the point at which the force was applied. 
The same causes that give rise to hemorrhage between the periosteum 
and bone elsewhere, frequently induce extravasation between the dura 
mater and the inner table of the skull ; but they are all of a mechanical 
nature. A form of inflammation that we very commonly meet with in 
the dura mater is that resulting from inflammation occurring in the 
internal auditory passages and the cells of the mastoid process. This 
form is not only secondary, but also of a dyscrasic character; it is met 
with chiefly in childhood and in scrofulous individuals. As infants may 
be affected with otitis, it often becomes a matter of difficulty to form a 
correct diagnosis at the commencement of the disease, when remedies 
are most likely to arrest it and prove beneficial. The disease may be 
initiated in the mucous membrane or the bone, and as the morbid process 
extends towards the cavity of the cranium, effusion of lymph or pus 
takes place under the dura mater, and the brain itself generally becomes 
involved. The dura mater is often found black and sloughy, especially 
over the diseased portion of bone; and it is a curious fact, illustrating 
the propagation of disease from one tissue to another without actual 
contact of the morbid process, that there need not necessarily be a per- 
foration of the pars petrosa to induce the inflammation of the dura mater. 
Mr. Toynbee has found that disease communicated to the encephalon in 
this manner more frequently induces morbid action in the cerebellum 



THE DURA MATER. 227 

than in the cerebrum. The same affection, purulent otorrhcea, when of 
long standing, is liable to induce inflammation in the sinuses of the dura 
mater; though other injuries, accompanied by purulent discharges, may 
also give rise to it. This particular form of phlebitis is mainly, if not 
exclusively met with in early life ; when the sinuses become inflamed in 
manhood, it is the result of external injury. The dura mater in such a 
case is found more closely adherent to the skull in the line of the inflamed 
sinuses and their vicinity than elsewhere, and the contents of the sinuses 
are fibrinous coagula, while their lining membrane is thickened and 
deprived of its lustre and smoothness, as in other cases of phlebitis. 
More or less adhesion is generally found to exist between the dura mater 
and the visceral plate of the arachnoid, when the former has suffered 
from inflammation. 

A gradual absorption of the dura mater from within, and consequent 
thinning and perforation, is occasionally observed to follow the growth 
of tumors, from the brain, or inner membranes ; it may also result from 
an unusual increase in the size and number of the Pacchionian bodies. 
Of these we shall have occasion to speak, when considering the relations 
of the arachnoid. 

Little is to be said concerning heterologous products occurring in the 
dura mater; the same cause which accounts for the comparative rarity 

Fig. 113 





A portion of dura mater, exhibiting a mass of bone-like substance of low conical form, attached to the side 
of the falx cerebri. The patient, 2S years old, had been subject to severe headaches from boyhood. A fort- 
night before death acute headache supervened, followed by delirium, partial paralysis, and insensibility. 
There was copious effusion of lymph in the cerebral membranes and ventricles. 

* Lateral view of the same. St. Bartholomew's Museum. Series vi. No. 46. Catalogue, vol. i. p. 201. 

of idiopathic inflammation in this membrane, suffices to explain why it 
is less frequently the seat of adventitious growths, than the other en- 
velops of the brain. Fibroid tumors are not unfrequent in connection 



228 THE DURA MATER. 

with the dura mater, from which they are more prone to arise than 
from other structures within the cranium; according to the prevailing 
law, that the physiological properties of a structure are liable to influence 
the morbid growths springing from it. In many instances these tumors 
would come under the head of hypertrophy, rather than of heterologous 
products. 

Both on the internal and external surface of the dura mater we fre- 
quently meet with small laminse of bone, which, in many instances, may 
be owing to chronic inflammatory action, of which no other trace is left. 
Some writers deny that the ossifications found on the inner surface of 
the dura mater are the products of this membrane; they view them 
rather as growths belonging to the arachnoid, an opinion to which we 
demur, both on account of the position in which these bone deposits are 
found, and from the general endowment of periosteal tissues, to which 
class the dura mater undoubtedly belongs, to generate bone. These 
ossifications, which are easily separated from the dura mater, and are 
generally met with along the falx, must not be confounded with the 
hypertrophy of the frontal and parietal bones, said to occur during 
pregnancy, and hence termed, by their discoverer, Rokitansky, puer- 
peral osteophyte. The most remarkable instances of genuine ossifica- 
tion, or of osseous deposit in the dura mater, are occasionally met with 
in chronic hydrocephalus, where it seems to indicate an effort of nature 
to afford extra protection to the diseased brain. A delineation of this 
affection is given in Dr. Bright's medical reports. 

Cysts of a lipomatous character are occasionally found attached to 
the dura mater. 

We have already seen that the dura mater is frequently subject to 
secondary, inflammation, owing to the extension of scrofulous or tuber- 
cular inflammation from adjoining bones ; it may thus, as also by exten- 
sion of tubercular disease from the cerebral tissue, become the seat of 
tubercular deposit; but the primary deposit of tubercle in the dura 
mater is, probably, never seen. Tumors of a cancerous nature more 
frequently grow from the dura mater; and, although the term " fungus 
of the dura mater" may occasionally have been falsely applied to car- 
cinomatous formations within the cranial bones, still, morbid anatomy 
supplies numerous instances of undoubted cancer of the dura mater. 
It occurs either in the form of an infiltration of the membrane; in con- 
sequence of which the dura mater becomes thickened, and may, by 
degrees, communicate the carcinomatous infection to the arachnoid, or 
the bones ; or it assumes the form of a rounded tumor, which generally 
consists of medullary cancer, and pushes its way through the adjoining 
bone. It is commonly very vascular, and generally occupies a situation 
near the vertex. When it forces its way through the osseous parietes, 
these form a ring round it, and the external table of the cranial bone 
will present a smaller opening than the internal table. Its growth 
becomes very much more rapid when it has passed the bounds in which 
it is first kept by the skull, and the soft parts soon become involved 
and perforated. 

The dura mater rarely exhibits any malformation or defect, beyond 
those spoken of, except that the falx is occasionally found cribrated, 



THE DURA MATER. 229 

and that in old people the dura mater presents slits in the vicinity of 
the longitudinal sinus, varying from two to four lines in length, through 
which the Pacchionian glands have forced their way. 

The records of the Pathological Society of London contain the account 
of a very rare defect of the falx cerebri, exhibited by Mr. Shaw. 1 Dr. 
Bright 2 also gives a similar case, in which no trace of the process was 
visible anterior to the tentorium, and it was assumed that the defect, 
which occurred in a lady thirty years of age, had existed from birth. 

1 Reports of the Pathological Society, 1847-48, p. 178. 

2 Medical Reports, vol. i. p. 150. 



CHAPTER VIII. 

THE ARACHNOID AND PIA MATER. 

The traditional doctrine of anatomy, that the arachnoid is a serous 
membrane of the same character as the pleura or pericardium, has 
found powerful opponents in Doctors Henle and Kolliker, who have 
shown that the external lamina is nothing more than an epithelial layer 
investing the dura mater. It must also be remembered that the arach- 
noid is entirely dependent for its supply of blood upon the pia mater ; 
and that, consequently, in health as well as disease, the condition of 
these two structures necessarily bears a very intimate mutual relation. 
The pathologist has, instinctively as it were, adopted this view; inasmuch 
as the term meningitis is generally understood to comprise inflammation 
of the arachnoid and the pia mater, to the exclusion of inflammation of 
the dura mater, which is not implied in the name ; while arachnitis is 
commonly used to designate disease of the arachnoid, as well as the pia 
mater, although etymology would not sanction such an interpretation. 
The best authorities of our own country, on subjects connected with the 
pathology of the brain and its membranes, as Doctors Watson, Aber- 
crombie, and Bright, are opposed to over-refinement in these distinc- 
tions, and are inclined to deny the limitation of disease to one or the 
other of the structures under consideration. It certainly is more prac- 
tical, and less likely to mislead the student, if we treat of the morbid 
appearances of the arachnoid and pia mater under one head, pointing 
out as we go on those cases and diseases in which the one or the other 
may appear exclusively or mainly implicated. The arachnoid depends 
solely for its supply of blood upon the pia mater, which may, therefore, 
fairly be regarded as its matrix ; in fact, it is very doubtful whether the 
former contains any bloodvessels of its own ; and, although it is com- 
monly assumed that the arachnoid possesses the power of secretion, this 
would seem rather to be of a mechanical than of a vital nature. 

Though the traces of active congestion or hypergemia of the arachnoid 
are not visible to the eye after death, we constantly meet with changes 
in the physical characters of the membrane which are the result of 
increased action, though the history of the individuals fails to show the 
occurrence of actual inflammation ; opacity and thickening of the arach- 
noid, especially on the surface of the hemispheres, is so frequent after the 
middle period of life as almost to merit being classed under the changes 
of involution, but it is most marked in habitual drunkards ; in delirium 
tremens, it is often the only disorganization to be found in the cranial 
cavity. This opacity is commonly accompanied by more or less serous 



THE ARACHNOID AND PIA MATER. 231 

effusion, which fills the sulci, and raises the membrane from the surface 
of the brain. Instead of being transparent, and allowing the vessels of 
the pia mater to shine through, the surface looks milky to a greater or 
less extent, and more particularly on the surface of the hemispheres. 
Owing to the obliteration of the sulci by the serum, the affected portion 
of the cerebrum often looks as if the convolutions were compressed, but 
on removal of the serum the cause of this appearance at once becomes 
evident. The subarachnoid effusion may be independent of any affection 
of the arachnoid, and be solely due to congestion of the pia mater; we 
should then find no adhesion between the tissues, the arachnoid retains 
its transparency, and the fluid is more prone to follow the laws of gravi- 
tation, and form pouches at the dependent portions of the organ. 

It may fairly be questioned whether the subarachnoid fluid is, in any 
way, due to the action of the arachnoid membrane. Whenever we find 
serum between the layers of the arachnoid, and in the ventricles, to 
adhere to the received terminology, it is right to refer it to that mem- 
brane ; but the vicinity of a congeries of vessels, and the known laws 
of transudation, certainly favor the view that subarachnoid effusion is 
attributable to the pia mater only. Congestion of the vascular network 
contained in this membrane is extremely frequent, though we are more 
frequently left to infer it, during life, than that we find it after death. 
It is the very nature of congestion to disappear in articulo mortis. 
Still, there is a sufficient number of affections in which the vessels of 
the pia mater have been shown to be gorged with blood, without any 
further accompanying morbid conditions of the adjoining structures; 
thus, we meet with it in cases of pertussis, of fever, of capillary bron- 
chitis, or disease of the heart. The congestion may, in the latter case 
more particularly, attain an extreme degree, so that, the blood not having 
room in the veins, we find dark venous-colored blood even in the larger 
arteries. 

There is no doubt that, occasionally, the subarachnoid fluid is attri- 

Fig. 114. 




Subarachnoid effusion on the upper surface of the anterior lobe, causing an apparent obliteration of the 
interstices between the convolutions, and accompanied by increased vascularity. 
* Enlarged Pacchionian bodies. 



32 HEMORRHAGE INTO THE ARACHNOID. 

butable to cadaveric changes ; it is, therefore, necessary to be circum- 
spect in at once attributing its presence to antecedent morbid action. 
The amount and position, and, more particularly, the concomitant ap- 
pearances of the pia mater and arachoid, must assist us in determining 
the question in the individual case. 

It~is not yet decided whether the small nodules, which are found in 
almost every brain, but become more numerous with advancing age, and 
have received the name glandulse Pacchioni, 1 are pathological products, 
or normal constituents. A superficial examination suffices to show that 
they are not what their first discoverer assumed them to be, conglobate 
lymphatic glands. They consist of an irregular fibrous network, contain- 
ing some albuminous granular matter, and generally occupy the vicinity 
of the mesial line of the surface. They often cause perforations of the 
dura mater, and may thus appear to belong to this membrane, when the 
brain is taken out in all its envelops. Their development, at times, is 
so considerable as even to induce absorption and thinning of the skull- 
cap. The term arachnoid granulations, applied to them by Louis, is 
probably as correct a designation as any that has been given them, and 
we should be inclined to attribute to them no higher importance than 
that belonging to warty indurations on the surface of the body. Luschka, 
who has especially investigated the Pacchionian bodies, confirms this 
view, and describes them as cactus-like projections from the arachnoid, 
of a fibrous organization, vascular, and covered by a scanty epithelium. 
He regards them as normal constituents of the membrane, but states 
that the hypertrophy to which they are liable may be the cause of death 
by the pressure they occasion. 

The arachnoid is occasionally found to present an unctuous sensation 
to the finger, without any marked morbid changes being discoverable 
in its vicinity ; though there is generally considerable disease in some 
part of the brain, which would account for a change of nutrition and 
secretion in a membrane like the arachnoid. This is the case in four 
out of five cases in which Dr. Bright applies the term to the arachnoid. 



HEMORRHAGE INTO THE ARACHNOID. 

We come now to the consideration of hemorrhage into the cavity of 
the arachnoid, a subject which presents a peculiar interest, from being 
the form of cerebral sanguineous effusion most common in childhood ; 
the reverse condition obtains in adult life, when hemorrhage within the 
cerebral tissue is the prevailing form. In neither case do we generally 
succeed in tracing the mouths of the vessels from which the discharge 
has proceeded ; though it is easier to do so than in most other hemor- 
rhages. In fact, Dr. Watson 2 lays it down as a rule, that, while the 
hemorrhages occurring in the lungs, and other organs of the body, are 
due to exhalation, those occurring within the cranium are attributable 
to the actual rupture of a larger vessel. We have already alluded to 

1 Ant. Pacchioni Dissert. Epistolaris de Glandulis Conglobatis Durse Meningis. Romse, 
1705. 

2 Lectures on the Practice of Physic, &c. vol. i. p. 494. 



HEMOKKHAGE INTO THE ARACHNOID. 



233 



one variety of hemorrhage occurring in the tissues of the head in the 
new-born infant, which we stated to be the result of the mechanical 
pressure exerted 'during parturition ; the same cause may give rise to 
arachnoidal effusion, which then commonly and speedily proves fatal. 
In this case, we find a larger or smaller quantity of fluid blood investing 
the upper surface of the brain ; but, if the child survives the immediate 
shock of the apoplectic seizure, the effused blood will undergo that 
series of changes, which indicate the tendency of the natural processes 
to restore the parts to their normal condition. The first step is the 
formation of a coagulum ; the fluid portions are first absorbed, then, by 
degrees, the coloring matter passes through various changes till it also 
disappears, and we then find, in the place of the original coagulum, a 
membranous formation, which is more or less organized, and may be 
shown to contain a capillary system of its own. It is a singular act in 
the pathology of the disease, to which MM. Rilliet and Barthez were 
the first to draw attention, that, unlike cerebral hemorrhage in the 
adult, it rarely gives rise to paralysis in the child; a circumstance ex- 
plained by Dr. West, 1 upon the principle of the blood in the latter 
instance being almost invariably effused into the cavity of the arach- 
noid, in consequence of which, the effects of the pressure act more uni- 
formly upon all the contents of the cranium. The changes in the 
effused blood may, however, assume another form than the one above 
described, and it is important to be aware of the circumstance, as it 
may stimulate hydrocephalus. Instead of the serum being absorbed, 

Fig. 115. 




This drawing represents a portion of dura mater divided from above, and showing a sac which was filled 
with coagulated blood. The coats of the sac presented nearly the same thickness as the dura mater.— St. 
Bartholomew's Museum. Series vi. No. 25. 

it may become inclosed in a false membrane, and remain as a persistent 
sac, exerting an amount of constant pressure upon the subjacent brain, 
sufficient to cause the flattening of the surface, and to induce, as they 
generally do, a considerable impairment of the intellect. When these 



1 Lectures on the Diseases of Infancy and Childhood. 
1848, p. 40. 



By C. West, M. D., London, 



234 ARACHNITIS. 

cysts are once formed they have a great power of passive resistance, 
and rarely diminish in size. 

Three interesting and instructive cases of superficial hemorrhage 
occurring in the adult, are given by Dr. Abercrombie; 1 and we also find 
a few instances recorded by Dr. Bright. 2 In the former, nothing was 
found either in the brain or the other viscera to account for the effusion ; 
in one of the cases contained in the Medical Reports there was a hyper- 
trophy of the heart ; in another, the hemorrhage was due to the rupture 
of a small aneurism; in a third, no lesions were found ; and in two others 
the hemorrhage was attributable to a fall, and the viscera do not appear 
to have presented any disorganization. 



ARACHNITIS. 

Arachnitis is a term used synonymously with meningitis, to designate 
inflammation of the arachnoid and the pia mater. The nosologist may 
at the desk draw numerous fine distinctions, and classify symptoms so 
as to produce a uniform system of morbid processes; but nature does not 
bind herself to laws of this description. This remark applies forcibly 
to the attempts made to dissever inflammation of the visceral plate of 
the arachnoid from inflammation of the subjacent pia mater. Whether 
in the course of pathological research we shall be justified in establish- 
ing more systematic divisions than we are now able to do, is not the 
question ; but we deem it especially our duty, throughout this work, to 
place before the student of pathology facts which he may recognize in 
the dead-house, from their having been previously observed by trust- 
worthy inquirers, rather than to show him a maze of systems which have 
long been the opprobrium of scientific medicine. The subject imme- 
diately before us is a stumbling-block to the practitioner, as much or 
more than it has been to the pathological anatomist. The former has 
allowed early and traditional impressions of the necessity of employing 
powerful antiphlogistic treatment in all cases where heat of surface, 
restlessness, a tendency to, or actual convulsions, the drawn-in thumb, 
and other well-known symptoms, seemed to indicate inflammatory action ; 
and many a child has been sacrificed at the altar of school-science, where 
the avoidance of injurious influences, or a strengthening regimen, would 
have succeeded in restoring the patient. Similar observations apply to 
much of our treatment in cerebral affections of adults, in whom cephalic 
symptoms are, even at the present day, too uniformly looked upon as 
the legitimate excuse for the application of our entire antiphlogistic 
apparatus. These remarks have suggested themselves by the great 
difference in the causes and course of several diseases, which are each 
due to, or connected with, inflammatory conditions of the pia mater and 
arachnoid ; and there is also one disease which must be classed with the 
former, which with symptoms resembling those of meningitis leaves no 

1 Pathol, and Pract. Researches, &c. p. 242. 

2 Medical Reports, &c, p. 26b'. See, also, Mr. Prescott Hewett's paper in theMedico- 
Chir. Trans., vol. xxviii. 



AKACHNITIS. 235 

trace of inflammatory or morbid action. Under the first head we class 
simple meningitis and tubercular meningitis; under the second, we allude 
to hydrencephaloid disease, to which Marshall Hall 1 first drew attention, 
and the analogue of which is presented to us in the adult, in that form 
of cephalic disease, termed somewhat indefinitely, serous apoplexy. In 
a case of simple acute meningitis, three points especially deserve atten- 
tion: the vascularity of the membranes, the adventitious membrane 
formed between the arachnoid and the pia mater, and the effusion of 
serum or pus in the same position. We may, according to the stage 
and duration of the disease, meet with either of these appearances, or 
they may be combined in the same individual. If the patient has died 
in the early stage of the disease, we find, on removing the dura mater, 
that the subjacent membrane shows a great increase of vascularity, 
which may be so intense as almost to resemble the effusion of blood; 
the eye and the touch will, however, speedily detect the real nature of 
the discoloration. The congestion spreads more or less over the surface, 
or appears in circumscribed patches; on removing a portion of the 
arachnoid, we shall find the congested vessels dipping down with the pia 
mater between the convolutions. If effusion of lymph has taken place, 
a membranous expansion will be found here and there to intervene be- 
tween the two meninges, causing a sort of marbled appearance, or bands 
stretching from one convolution to another. The effused lymph attains 
the thickness of a wafer and more, and most commonly occupies the 
upper portion of the hemispheres. The lymph itself dips down into the 
convolutions, and presents the same variations of density and consistency 
that this product of inflammation offers elsewhere in proportion to the 
date of its effusion. Some serous effusion beneath the arachnoid of the 

Fig. 116. 




Portion of upper cerebral hemisphere of a young woman, aged 27, with purulent effusion under the arach- 
noid; there were two yellow symmetrical patches, one on each parietal surface, concealing the subjacent 



convolutions. 



base, especially about the optic chiasma, which causes the part to re- 
semble the appearance of jelly, and a small amount of similar fluid (from 
two drachms to an ounce) in the ventricles, are often found in this form 

1 On Diseases and Derangements of the Nervous System. London, 1841. 



236 ARACHNITIS. 

of arachnitis, though it is by no means a necessary accompaniment. 
The brain, in these cases of simple meningitis offers no appreciable de- 
rangement of structure, though the symptoms during life may have 
shown very manifestly that its functions were involved. The formation 
of pus in the course of arachnitis is not an occurrence of frequency, but 
it is necessary to bear in mind that it is a pathological fact. A remark- 
able instance of this occurred under our observation recently, at St. 
Mary's Hospital, in a young woman in whom sudden and unexpected 
coma supervened, and terminated, after thirty-six hours, in death. She 
had previously suffered from otorrhoea ; but on her admission gave no 
evidence of cephalic disease, nor was any direct connection traced after 
death between the affection of the ear and the meningitis which was 
found to have caused her death. Here two yellow patches were dis- 
covered on each parietal surface of the brain, owing to an accumulation 
of pus spread out under the meninges; the microscopic examination of 
the fluid satisfactorily demonstrated the characters of pus. 

Cases of meningitis are now and then met with, in which the arach- 
noid appears perfectly transparent and normal, while there is vascularity 
of the pia mater with subarachnoid effusion. We should here be in- 
clined to assume an idiopathic affection of the pia mater, and it cannot 
be denied that the evidence in favor of primary and independent disease 
in that membrane, is stronger than any arguments adducible in favor of 
the same disposition in the arachnoid. We cannot blind ourselves to 
the fact that the latter differs much in its behavior from the serous 
membranes of the thorax and abdomen, in the rarity of inflammatory 
effusion occurring within what we must term the sac of the arachnoid, 
if we continue to look upon it in the same light as a serous membrane. 
It is highly desirable that anatomists should settle its normal relations, 
in order that the deviations occurring in morbid processes may receive 
the correct and proper estimation. Thus, with regard to the effusion 
occurring within the ventricles of the brain, which are commonly taught 
to possess an arachnoideal lining, it evidently offers many relations 
different from the arachnoideal effusions occurring on the surface of the 
brain ; nor is it quite intelligible why the secretion into the cavity of 
the ventricles should so rarely be found to communicate with the super- 
ficial arachnoideal space. Kolliker, 1 whose profound knowledge of 
anatomy and physiology renders him an authority in the matter, says : 
" Those who state that the arachnoid lines the ventricles of the brain, 
and the processes of the pia mater contained in them, suppose a thing 
that is impossible, viz., that the arachnoid passes through the pia 
mater, and invests the surface of the plexuses, which is actually an 
internal one." 

If we examine the inflamed pia mater under the microscope, we shall 
find the smaller vessels studded with exudation matter, in the shape of 
minute oily-looking vesicles ; we have seen it as in the adjoining draw- 
ing, so bounded by the outline of the vessel, that it seemed to lie within 
its coats ; there is no d priori reason why it should not be formed in 
the vessels. We also see numerous so-called inflammation corpuscles, 

1 Mikroskopische Anatomie von Dr. A. Kolliker, 1850, vol. ii. p. 501. 



ARACHNITIS, 



237 



which would appear rather to be a peculiar aggregation of the exudation 
matter than distinct formations ; they are sometimes possessed of a 
delicate envelop, at others they are devoid of it ; they may be appro- 
Fig. 117. 




Meningeal vessels invested and surrounded by exudation matter, and glomeruli or exudation corpuscles, 
from a young man, aged 34, who died in consequence of injury to the head, followed by meningitis ; magn. 
270 di. 

priately compared to a mulberry — they generally, also, offer a brownish 
tint. We owe the knowledge of these corpuscles to Professors Gluge 



Fig. 118. 



Fig. 119. 





^ : y. 



Further specimens of the microscopic appearances of the vessels in meningitis. 

and Bennett ; the former was the first to show their connection with 
inflammation generally, the latter drew attention to their presence in 
inflammatory affections of the brain and its membranes. 

Much confusion has arisen from the misapplication of the term hy- 
drocephalus, as it has been used to designate a variety of diseases, 
simply on account of their resembling one another in a comparatively 



238 ARACHNITIS. 

accidental feature; and we would, therefore, follow in the steps of those 
authors who limit the term to the dropsical effusion of serous fluid 
within the cranium, unaccompanied by marked symptoms of inflamma- 
tory action during life. We have already seen that an accumulation of 
serum beneath the arachnoid, or within the ventricles, is a common 
feature in both acute and chronic meningitis ; and though an affection 
of serious import, we have abundant evidence of the value of thera- 
peutic proceeding in arresting and completely removing the disease and 
all its effects. Not so with what is commonly called chronic hydro- 
cephalus, or what ought exclusively to receive the name of hydro- 
cephalus, while certain forms of meningitis should designate the disease 
acute hydrocephalus ; nothing is more liable to mislead the student, or 
to perpetuate error, than a want of precision in our nomenclature. We 
must never forget that the effusion of serum is only a product of mor- 
bid action ; and that inflammation, mechanical obstruction, ansemia, 
blood-poisoning, scrofulous cachexia, diseased conditions essentially 
differing from one another, may each of them give rise to a secretion 
of fluid into serous cavities. It is erroneous, and likely to lead to the 
most injurious practice, if we apply a name to a symptom, by which it 
becomes identified with the most opposite diseases. 

Whether we look upon the arachnoid as a serous membrane or not, 
and whether or not we continue to consider the lining of the ventricles 
as a prolongation of the external arachnoid, there is no doubt of the 
close resemblance between the structure of the latter, with this differ- 
ence, that while the superficial arachnoid overlays the pia mater, the 
lining of the ventricles is in direct opposition with the gray matter of 
the brain. In examining the pathology of the brain, we shall have 
occasion again to allude to the ventricles, but it seems advisable to ad- 
vert to some changes which occur in them at this part of our inquiry. 
Here, as in the superficial arachnoid, we see no traces of active con- 
gestion, even where we have the undoubted evidence of inflammatory 
action. Hemorrhage into the ventricles is invariably the result of in- 
jury to or disease of the brain, and the effusion of blood into them is 
stated by Dr. Bright to be the most rapidly fatal of any kind of apo- 
plexy. It has already been mentioned that in meningitis it is common 
to find an increase in the ordinary amount of secretion of the ventricu- 
lar fluid ; but while this may be measured by drachms, the fluid accu- 
mulating in hydrocephalus reaches to several pints, and is commonly 
the result of defective action, not so much in the membrane as in the 
cerebral and general circulation. Though we fail to find a congested 
state of the vessels in the ventricular lining membrane, it often pre- 
sents an indurated, thickened, and granular condition, indicative of 
previous inflammation. The septum lucidum, and the commissura 
mollis, are generally involved in the morbid processes occurring in the 
ventricles : the former is more particularly liable to suffer in chronic 
hydrocephalus from distension ; and yielding to the mechanical pressure, 
it becomes perforated, and allows of free communication between the 
two cavities. The granulations of the arachnoid occasionally become 
prominent, and even pediculated ; at other times the inflammatory pro- 
duct is rather of an adhesive character, and the opposite sides of the 



TUBERCULAR MENINGITIS. 239 

ventricles, especially the corpora striata, may then become agglutinated 
to one another. 

It must be considered as one of the great goals which this and future 
generations of scientific inquirers have to pursue, in how far these and 
similar changes in the membranous or parenchymatous structures are to 
be attributed to dyscrasic conditions. The combined modes of research 
represented by the microscope and the test tube, must assist in solving 
many of the problems that yet puzzle the physician ; and if there are 
various cachectic conditions differing essentially in their character, of 
which we have no doubt, we must hope to succeed eventually in demon- 
strating them more palpably than has yet been done, both in the living 
and the dead subject. That the rheumatic and gouty diathesis should 
produce their definite lesions within the cranium, as well as externally, 
can scarcely be denied ; but we do not possess sufficiently satisfactory 
evidence. Purpuric spots are occasionally seen on the arachnoid, indi- 
cating a scorbutic crasis ; but none of the erases have hitherto been 
shown to have such decided traces within the cranium as the scrofulous 
or tubercular. The frequency of meningitis in childhood is in a great 
measure due to this fact ; and to it we may also in a measure attribute 
the great prevailing fatality, owing to the misconceptions that the term 
inflammation gave rise to ; and which, therefore, seemed to necessitate 
antiphlogistic treatment of as active a character as if we had to deal 
with sthenic inflammation. 



TUBERCULAR MENINGITIS. 

The deposit of tubercle on the pia mater of the brain occurs in the 
shape of small miliary granules, resembling the Pacchionian bodies in 

Fig. 120. 




Deposit of tubercular matter in the Sylvian fissure of the brain of a child, aged 19 months, who died ten 
days from the first appearance of head symptoms, -which were treated antiphlogistically. The white circular 
spots represent the tubercles, which were surrounded by highly congested bloodvessels. The white deposit 
examined by the microscope showed granular matter and granular corpuscles varying in size. 

appearance, but differing from them both in their site and in their micro- 
scopic relations. They are not seen on the free surface of the arach- 



240 HYDROCEPHALUS. 

noid; and, in fact, seem in no way connected with this membrane; a 
point which establishes a marked difference between it and the serous 
membranes of the thorax and the abdomen. They are found most fre- 
quently deeply within the Sylvian fissure, in the convolutions of the 
brain, and at the base ; they are of the size of pins' heads, and appear 
in the form of gray granulations, imbedded among a vascular network ; 
they are very rarely found upon the cerebellum. A careful examina- 
tion is necessary, to prevent their being overlooked; but in a therapeu- 
tic point of view, it is most important that their presence should be duly 
appreciated, and that they should be taken as an indication of a state of 
the blood, requiring a different line of treatment from what ought to be 
adopted in meningitis, unconnected with the pathological condition of 
the fluids that tubercle implies. It is only by the aid of the microscope 
that we have been able positively to determine the real nature of these 
granulations, for they closely resemble a mere puckering of the mem- 
brane ; seen under a power of three or four hundred diameters, their 
elements resolve themselves into the corpuscles peculiar to tubercle, 
possessing a faint outline, with granular contents, and surrounded by 
granular matter. The tubercular corpuscles must not be confounded 
with epithelium, which may be seen under the same field, and which is 
to be distinguished by the nuclei it contains, within which, again, one or 
two nucleoli are visible. 

This form of meningitis is generally met with in connection with or 
secondary to tuberculosis of other organs; though we see it occasionally 
in the idiopathic form, as in the instance from which our delineation 
was taken, where no tubercular deposit was found in any of the viscera 
beside the brain. In the former case, the tubercular deposit may take 
place so insidiously as to offer no marked inflammatory symptoms during 
life; and it is only on the dissecting-table that the physician becomes 
aware of the cerebral disease. It must, therefore, be borne in mind 
that scrofulous children have a tendency to become afflicted in this 
manner; and it is an additional reason for watching them with care, 
and avoiding such debilitating measures as would be likely to encourage 
the dyscrasia. It is not our province to enter into the consideration of 
nosological or therapeutic inquiries, but we cannot avoid remarking 
that the frequency of tubercular deposit in the pia mater in children is 
a strong argument against those powerful depleting measures which 
inflammatory symptoms presenting themselves in the head of a young 
subject, are generally calculated to provoke. 



HYDROCEPHALUS. 

The irritation of the tubercular deposit is very liable to induce the 
secretion of serum, either beneath the arachnoid membrane, or in the 
cavities of the brain, and this leads us to the consideration of that for- 
midable disease of childhood, hydrocephalus. 

The etymology of the term indicates the main feature that character- 
izes the morbid condition, and, provided its application be limited to the 
class under consideration, it is not likely to mislead the practitioner, as 



HYDROCEPHALUS. 241 

it implies no theory. It is truly a dropsy of the brain, and it is an 
affection which, like dropsies in other parts of the animal economy, is 
favored by a relaxed and soft condition of the surrounding tissues ; the 
anatomical peculiarities of the foetal and infant head at once indicate a 
probable reason why it should commence at those periods; while the 
mal-nutrition upon which it is based, and the further impairment of the 
important organ in which it occurs, is a sufficient ground for explaining 
its great fatality, and the infrequency of the child affected with it sur- 
viving to reach manhood. Instances are, however, on record, of indi- 
viduals in whom the parts accommodated themselves to the morbid effu- 
sion, and life was prolonged far beyond the period of childhood. The 
most celebrated case of this kind is that of James Cardinal, 1 who at- 
tained the age of twenty-nine, though he had been hydrocephalic from 
within a fortnight after birth; the circumference of his skull measured 
at the period of his death thirty-two inches and a quarter. 

The accumulation of serum frequently commences in the ventricles, 
which are the most ordinary seat of hydrocephalus, or on the surface of 
the brain, during the last months of foetal life; it may become a cir- 
cumstance for the consideration of the accoucheur during parturition, 

Fig. 121. 




A hydrocephalic skull from a girl aged 11 years : the enlargement of the skull is effected hy its elongation, 
and hy the depression and hollowing of its base. An increase of width appears to have been prevented by 
the premature and complete closure of the sagittal suture. The coronal suture, and that between the frontal 
bone and the suture, also of the splenoid, are wide open. The superior walls of the orbits are pressed down, 
wards. The bones generally are thin and light. St. Bartholomew's Museum, sub series e, 2. 

not so much from the increased size of the head presenting an obstacle, 
because there is even a greater compressibility than usual, but from the 
head being so soft as not to offer a sufficient fulcrum for the labor pains 
to act upon, or, in case of operative interference, for the instruments to 
obtain a sufficient purchase. The child may, however, be born appa- 
rently without a blemish, though it does not thrive well, and a few 
weeks after birth, or at least within the first three years of life, the 
head appears to increase unduly in size, and the ossification of the fon- 
tanelles is retarded. Dr. West states, 2 that out of fifty cases, symp- 
toms of hydrocephalus w T ere observed in forty-six before they were six 

1 Dr. Bright's Medical Reports, p. 431. 

2 On the Diseases of Infancy, 1848, p. 84. 

16 



242 HYDROCEPHALUS. 

months old, and in twelve of these the malady was congenital, and that 
in nineteen more it came on before the completion of the third month. 
The accumulation of fluid may amount to as much as ten pounds. The 
increase in the quantity is greatest during the first months, and dimi- 
nishes or even remains stationary if the child survives ; the circumfer- 
ence of the head corresponds to these relations ; thus, it is not uncom- 
mon to find the circumference to attain as much as twenty-six inches 
and more, during the first three months, and to vary but little subse- 
quently. 

The immediate pathological effect of this secretion is to compress the 
parts within the skull, and to distend and prevent the due ossification 
of the cranium ; the frontal bone is made to protrude, and the parietal 
bones, from their yielding character, bulge out considerably on each 
side, while the intervening soft parts present fluctuation. Ossification 
takes place, though irregularly, and at a much later period, and we 
have already seen that a succedaneous deposit of bone is occasionally 
effected in the dura mater. The sutures of the cranial bones are not 
formed as in the healthy skull, but are less serrated, and therefore more 
ready to yield to pressure from within, which they occasionally do, after 
they have closed, in the event of a sudden increase of the fluid. The 
ossification does not proceed with the normal regularity, but numerous 
centres form, and thus we meet with more or less ossa triquetra in the 
line of the sutures. In an almost similar ratio, we shall find the brain 
altered in its relations. If the accumulation has been confined to the 
ventricular cavities, the entire brain will be distended, and its tissue is 
generally found softened and pultaceous, from the fluid having infiltrated 
the cerebral tissues. The distension may be so excessive as to reduce 
the hemispheres to the thickness of a sheet of paper ; but more com- 
monly the parietes give way, and allow the fluid of the two sides to 
combine ; and the pressure may then, as in the case of Cardinal, sepa- 
rate the hemispheres, and unfold them, "like the leaves of a book." 

Occasionally the fluid is limited to one side, and thus gives rise to an 
unilateral distension or obliquity. When the superficial arachnoid is 
the seat of the dropsy, the brain may, at first sight, appear altogether 
deficient ; but, on raising the sac, we shall find it pressed downwards and 
forwards, and presenting a state of extreme atrophy. 

It is usual to meet with some abnormal conditions of the vessels and 
the membranes in hydrocephalus, but we are unable to determine the 
relation that they bear to the morbid product — whether they are to be 
considered in the light of cause or effect ; though we find both Dr. 
West and MM. Rilliet and Barthez agreeing that hemorrhage into the 
cavity of the arachnoid may occasionally be the fons et origo malt. 
Rokitansky attaches more importance to hemorrhage, as occurring in 
the course of the disease. A thickening and opacity of the lining 
membrane of the cyst, with granular deposits, are the most common 
post-mortem appearances found in the arachnoid, while occasionally the 
formation of a new membrane, and the deposit of fine granular matter, 
causing a roughness ,of the surface, present themselves to the anato- 
mist. The occurrence of the latter suggests that there has been inter- 
current, subacute inflammation, and should warn us to remove all causes 



HYDROCEPHALUS. 243 

of irritation from an individual thus circumstanced. The vessels sub- 
jacent to the arachnoid are frequently enlarged, varicose, and congested. 
The fluid of hydrocephalus is of a limpid and transparent character, 
or more or less yellowish and opaque ; of a specific gravity rather lower 
than that of the serum of the blood, and containing, therefore, a smaller 
amount of solid constituents. When there is any opacity, this is found 
to be due to granular and nucleolar matter, mingled with epithelial 
debris. The fluid, when tested by heat and nitric acid, presents the 
characters of a solution of albumen, and is found to contain chloride of 
sodium, soda, and traces of salts of lime and potash ; and also, accord- 
ing to Dr. Bostock's investigation, urea. The results of his analysis 
of the hydrocephalic fluid of Cardinal are embodied in the following 
table : — 

Sp. gravity 1011.38 

Water 982.6 

Albumen ......... 6 

Chloride of sodium ....... 7 

Soda 1.4 

Urea and osmazome . . . . . . . 3 

Sulphuric acid, lime, potash . . . . .a trace 

1000.0 

The fact of urea being found in hydrocephalic fluid has not met with 
any attention on the part of other pathologists ; l but if it should prove 
to be the rule, it places this disease on a par with the ursemic cases, 
which are intimately connected with certain forms of renal disease, to 
which Drs. Bright and Christison first drew attention. The state of 
the kidneys is a point which merits more consideration in this disease 
than has hitherto been devoted to it, or we may say in infancy gene- 
rally. It is to the generic development of an affection like hydroce- 
phalus that we must look for the attainment of a means of cure ; for 
its products, though interesting to the pathologist, are unfortunately 
not of a character to yield either to the vis naturae or to medical treat- 
ment. From the early appearance of its symptoms it especially chal- 
lenges our attention to the state of health of the progenitors ; and 
though in many of the recorded • cases it is expressly stated that the 
mother's constitution had been sound, we must bear in mind how vague 
such data generally are, a\id that the hereditary influences are as inti- 
mately connected with the father as the mother. We know more of 
the relation existing between hydrocephalus and tubercle ; for the two 
are very commonly found associated. Scrofulous children very fre- 
quently present a very considerable amount of serous accumulation 
within the ventricles, without even having manifested any symptom of 
cerebral disease. 

We have spoken of hydrocephalus throughout as of a disease of 
childhood, and it is to early life that it mainly belongs. Several cases 
are, however, on record of the affection having supervened in the adult 
when there was no trace of previous cerebral disease. If it be found 

1 Dr. G-arrod has stated to us in conversation, that he has also found urea in hydroce- 
phalic fluid. 



244 ' CHOROID PLEXUS. 

that the diathesis upon which the disease is engrafted belongs equally 
to infancy and manhood, we shall easily be able to explain why the 
more prominent symptom of dropsical accumulation does not present 
itself frequently in the adult. The firm connection of the cranial bones, 
and the compression which they consequently exert, offer a mechanical 
impediment to the effusion, which can only take place at the expense of 
some other contents of the skull. The very congestion of the veins, 
which for instance exists in cases of uraemia, would militate against it. 

Several instances of an accumulation of serum in the cavity of the 
arachnoid or in the ventricles, and not offering any marked traces 
of active hyperemia or inflammation occurring in advanced life, may 
be found in the works of Professor Golis, Dr. Baillie, and Dr. Watson. 
They have received the name senile hydrocephalus, and such are the 
cases to which the nosological term of serous apoplexy ought to be re- 
stricted. The fact of Dean Swift having died of this affection, may 
serve to fix the subject in the memory. The immediate cause to which 
this may be most justly attributed is an atrophic condition of the brain, 
which gives rise to a vacuum, and hence to a discharge from the vessels, 
of that part of the blood which most readily transudes the coats ; the 
effused serum is peculiarly clear, and its quantity varies, according to 
the extent of cerebral atrophy, from two to six ounces. When we ex- 
amine into the morbid anatomy of the brain, we shall discuss the origin 
and causes of atrophy ; we have here only to do with one of its pro- 
ducts ; but it is apparent that in the present instance, as well as in the 
hydrocephalus of infants, the effusion is a symptom of a deeper-seated 
malady, and not truly an idiopathic affection. In senile as well as 
infantile hydrocephalus, the soft commissures, the septum, fornix, and 
adjoining parts, are commonly found softened ; but it is not always 
easy to form a positive opinion, whether this is a primary or secondary 
condition. Before dismissing this subject, we have to advert to a form 
of congenital hydrocephalus which has received the name of hernia 
cerebri, in which, owing to a deficiency in the cranial walls, a portion 
of the brain and its membranes are protruded. It is analogous to the 
spina bifida. 



CHOROID PLEXUS. 

The venous rete mirabile of man, known by the name of the choroid 
plexus, appears in a measure to possess a vitality independent of the 
membrane, the pia mater, of which it is an appendix. It is impossible 
to doubt that it plays a most important part in equalizing and balancing 
the circulation within the cranium, within the limits of health, and that 
equally its peculiar relation to the cavity in which it is suspended must 
give rise to important variations in disease ; the physical laws of exos- 
mosis and endosmosis may, without any stretch of hypothesis, be sup- 
posed to operate with peculiar vigor, and it is not unreasonable to 
assume in the choroid plexus a powerful agent of secretion and absorp- 
tion. The amount of blood in the plexus found after death varies much 
— at one time it is full, and the vessels stand out in relief; at others it 



CHOROID PLEXUS. 



245 



is collapsed, and contains scarcely enough blood to color it. There is no 
necessary relation between the amount of vascularity or exudation, and 
the congestion or inflammation of the pia mater ; thus, we may find the 
surface of the brain covered with a highly vascular pia mater, while the 
choroid plexuses present an exsanguine appearance ; a circumstance 
which rather confirms our view of the physiological character of the 
latter. The greater density of the coats of the vessels in the choroid 
than in other parts, may account for the rarity of their being the source 
of hemorrhage; indurated yellow bodies are, however, occasionally found 
in them which are referable to former effusion. The morbid appear- 
ances most commonly found in the plexuses are round or oval bodies of 
a yellowish tinge, apparently formed of concentric laminae, which only 
become more apparent on the addition of acetic acid. They are ordi- 
narily microscopic, but are often found in considerable numbers, and 
occasionally accumulate into masses of the size of a pea or small nut. 




The upper figure represents a choroid plexus with several small tumors at * * *, supposed at first to 
have been tubercular ; they proved to consist of aggregations of Sncentric corpuscles, cholesterin, and pure 
oil, united by areolar tissue ; the concentric corpuscles which are shown below the plexus are magnified 100 
diam. 



It is evident that they are phosphatic connections enveloped by layers 
of organic material. Acetic acid acts very slowly upon them, destroy- 
ing their opacity, but not altering their configuration. Muriatic acid 
destroys their opacity by removing the phosphate of lime, and leaves 
transparent rings of animal matter. They are not found in early in- 
fancy, but occur so frequently in advanced life that they almost appear 
to be a normal constituent from their behavior with reagents. Vir- 
chow calls them corpora amylacea, but the term concentric corpuscles, 
suggested by Dr. H. Jones, is more appropriate. Similar formations 
are met with in other parts of the body: thus, we have seen them in an 
adventitious membrane formed in the kidney. Cysts of the choroid 
plexus are more frequently mentioned by authors on account of their 
being visible to the naked eye ; they are minute, transparent vesicles, 
varying in size from a poppy seed to a small pea ; and we generally 
meet with them in brains, in which we also find evidence of inflammation 



246 CHOROID PLEXUS. 

of the lining membrane of the ventricles. They sometimes contain a 
milky fluid, and may present incrustations of a sabulous character. 
They have been erroneously regarded as hydatids, but there is no evi- 
dence of their belonging to this class of parasitic formations ; they 
would rather seem to be due to a condensation of the epithelial covering 
of the plexus, and an accumulation of fluid beneath it, limited by an 
effusion of plastic matter. An hypertrophy of the epithelium, which 
covers the choroideal vessels, is very commonly observed in advanced 
age — though we have not been able, as yet, to trace any definite rela- 
tion between this condition and certain forms of disease. The choroid 




© ® n 



Portion of a choroid plexus, exhibiting a fatty degeneration of the epithelium, from a female aged 45, who 
for 14 days previous to her death was subject to convulsive fits and various cerebral symptoms. No morbid 
condition was observed in the brain, but considerable deposit of oil in the choroid plexuses ; in one, there was 
a small lump of fat. A. The loop of the plexus dotted with oil, 120 diam. B. The epithelium, containing oil- 
drops, magnified 360 diam. 

plexus is frequently found of a fleshy consistency, probably owing to 
some interstitial effusion having taken place ; and we also find small 
fatty tumors on the plexuses, as well as a microscopic deposit of fat in 
the shape of minute oil-globules, dotting the surface of the vessels, but 
for the most part inclosed irf the epithelium. 



CHAPTER IX. 

THE BRAIN.— GENERAL OBSERVATIONS. 

The question that meets us at the threshold of an inquiry into the 
pathological conditions of the brain, is whether the amount of blood 
contained within the cranium in the adult, can vary. There is no diffi- 
culty in determining the question in the child, for there, as long as the 
fontanelles are unclosed by bone, the cerebral circulation necessarily 
obeys exactly the same laws as rule the general circulation; when the 
skull is completely formed, the pressure of the atmosphere is in a mea- 
sure withdrawn from the contents, and the variation in the amount of 
blood contained in the cerebral vessels is very much lessened. Still, in 
applying the law of atmospheric pressure to this subject, we must re- 
member that the column of blood reaching from the heart to the brain 
is not like the barometer, a single tube, with a vacuum at the closed 
end, but that the vessels may be compared to a curved tube, both ends 
of which are equally under the control of this law. If it were not so, 
respiration could not, independent of the heart's beat, exert any influ- 
ence upon the cerebral circulation. The presence of the ventricles, and 
of serosity in the cavities and subarachnoid fluid of the brain and spinal 
canal, is a further indication that there is a provision to meet this species 
of variation — for it is in obedience to this very law of atmospheric pres- 
sure, to assume that these fluids mutually assist one another, and as the 
walls of the cranium cannot collapse, keep up the balance of the circu- 
lation by vicarious action. "We have already seen that nature shows her 
horror vacui in senile hydrocephalus, where, if our explanation is cor- 
rect, the effusion is mainly due to the atrophy of the brain. While we 
admit, therefore, that the constriction placed upon the vessels of the 
brain and the peculiar character of the cranial contents, prevents as 
great a variation in the amount of the fluid contents as takes place in 
the thoracic or abdominal viscera, we feel assured that a variation does 
take place, and sufficient to account for many of the phenomena of 
nutrition and disease. It is important to place this question on a pro- 
per basis, as it is one that constantly suggests itself to the pathologist ; 
without a satisfactory explanation, we shall be constantly at a loss to 
find the proper terms for morbid conditions, and they would themselves 
appear to contradict our theories. We cannot enter further into this 
question, but we hope that the suggestions just thrown out may serve to 
reconcile some conflicting views on the subject. The positive denial of 
various physiologists, of any variation in the quantity of blood in the 
brain, apparently supported by such experiments as those of Dr. Kellie, 



248 THE BRAIN. 

has served not a little to confuse the student. Dr. Burrows 1 has inves- 
tigated this question fully, and from experiments and physiological 
considerations, arrives at the conclusion, which seems unavoidable to 
the practitioner of medicine, that the quantity of the blood within the 
cranium is extremely variable at different times, and under different 
circumstances. There is a peculiar feature in the white matter of the 
brain, which constantly forces itself on the notice of the microscopist, 
by impeding his investigation, and which has a strong bearing on the 
matter — it is the great elasticity of the medullary tissue; this resiliency, 
among others, is a counterpoise to the rigid structures enveloping' the 
brain. All inquirers are agreed that the relative amount of blood in 
the different sets of vessels, in the veins and arteries, varies considera- 
bly ; and on this point Dr. Kellie's experiments appear to afford conclu- 
sive evidence, though the examination of a few bodies would suffice to 
show the same thing. 

The importance of the study of the morbid phenomena met with in 
the brain is self-evident, both from the rank of the organ in the economy, 
and from the great frequency of cerebral disease. Thus we find, on re- 
ferring to the Registrar General's valuable statistical reports, that the 
deaths caused by diseases of the brain rank fourth in order of fatality. 
The average percentage of mortality in London from zymotic, tubercu- 
lar, pulmonary, and cerebral disease, appears from analysis of the deaths 
in ten weeks, selected promiscuously throughout the year 1851, to be 
respectively 19.9, 18.3, 15.5, and 12.1. 

We frequently make post-mortem investigations in cases where all the 
symptoms indicated that death proceeded from cerebral lesion, and 
where, nevertheless, we are unable to discover any disorganization such 
as would appear to justify the conclusion that this was the case. A cer- 
tain amount of hyperemia in some of the cranial contents may be all 
that presents itself to us, and even this may be absent. Sir Astley 
Cooper's experiments 2 upon rabbits, in which the vertebral arteries were 
alternately compressed and relaxed, after the carotids had been pre- 
viously tied, have sufficiently demonstrated the influence of the circula- 
tion upon the functions of the brain. The compression invariably pro- 
duced an instant arrest of respiration, convulsions, and apparent death, 
and when the finger was removed from the artery the animal gradually 
recovered. The symptoms closely resembled those of epilepsy in the 
human subject, to the illustration of which disease they are frequently 
applied. We have yet to determine the ratio in which mere pressure 
influences the cerebral functions, as compared with the frequency in 
which disturbance is excited, and a fatal issue produced by a poisoned 
condition of the blood, as in uraemia, resulting from granular degenera- 
tion of the kidneys. 

1 On Disorders of the Cerebral Circulation, London, 1846. 

2 Guy's Hospital Reports, vol. i. 1836, p. 465. 



CONGESTION". 249 



CONGESTION. 

"When the congestion of the brain is considerable, the entire organ 
may present an increase of volume and turgidity. On slicing it, the gray 
matter may exhibit a deeper tinge than usual, but its natural hue pre- 
vents the alteration of color from being very perceptible. The white 
matter shows an increase of the red dots indicating the bloodvessels, 
and may, as it does particularly in children, assume a general pinky 
tint from the same cause. This must not, however, be confounded with 
the color imparted to it by the knife as it divides the bloodvessels, and, 
according to the amount of blood contained in them, smears it over the 
brain surface; by carefully wiping or scraping it, we shall be enabled to 
determine to which cause the color is due. Scipion Pinel 1 dwells very 
forcibly upon the occurrence of congestion of the gray matter of the 
brain as the main pathological feature accompanying mania. He de- 
scribes the inner layer of the cortical tissue as presenting a lively red or 
violet tint, the white matter being less altered in this respect, but also 
offering a livid hue, with occasional blackish patches, or more or less 
extended ecchymoses. Congestion of the meninges is more frequently 
found independently of congestion of the brain than the* converse; but 
we must look for the latter more especially in cases in which death has 
taken place in consequence of poisoning from opium, in epilepsy and 
apoplexy, in bronchitis, hooping-cough, in fever accompanied by coma, 
and in hypertrophy of the heart and granular kidney. In a therapeutic 
point of view, the relation of congestion to cerebral symptoms is important, 
and the proceeding of Mr. Parry, 2 to compress the carotids in epilepti- 
form and other affections, probably dependent upon this derangement, 
is a practical application of the doctrine to therapeutics. The patho- 
logical effect of arresting the circulation in the vessels of the head is 
illustrated by cases like those referred to by Dr. Abercrombie, 3 in which, 
accidentally or intentionally, these vessels were closed, and animation 
temporarily suspended, until the constriction was removed. The frequent 
fatality of apoplectic affections, without leaving any appreciable trace, 
has been the cause, as the same author most justly observes, of the 
number and variety of speculations on the subject, which have certainly 
not tended to clear up the difficulty. Turgidity of the bloodvessels in 
the membranes and brain has been observed in the majority of lunatics, 
independent of other lesions; thus, Dr. Webster, in analyzing the records 
of Bethlem Hospital, finds this the case in eighty-nine out of one hundred 
and eight. 

Local congestions are occasionally met with limited to individual por- 
tions of the encephalon. There can be no doubt that an anaemic con- 
dition of the brain, as well as a cachectic state of the blood circulating 
in it, may induce, in a similar manner, disease and a fatal issue without 
offering any perceptible lesions. In these cases, the fibrous tissue of the 

1 Traite de Pathologie Cerebrale, p. 193. Paris, 1844. 

2 Collections from the Unpublished Writings of the late C. H. Parry, 1825, 

3 Diseases of the Brain, &c, p. 211. Edin. 1845. 



250 



HEMOKRHAGE. 



brain presents a more deadly white, and fewer red spots than in the 
normal condition, but we possess no means as yet of determining these 
relations by actual measurement; and in many instances where no organic 
change has taken place, the tonicity of the arteries may, in articulo 
mortis, restore the balance of the circulation in such a manner as really 
to remove all post-mortem effects. 



HEMORRHAGE. 

Congestion is a transition state to numerous cerebral lesions which 
leave sufficiently perceptible post-mortem effects. The first of these that 
we shall consider is hemorrhage, the most frequent cause of cerebral 
apoplexy, and an affection peculiarly belonging to advanced life; the 
disposition to it increasing in a direct ratio with the years of the indi- 
vidual. The greatest fatality, according to Dr. Burrows, exists between 
the age of sixty and seventy, while it is also found to occur more fre- 
quently in males than in females. The following table, which has been 
compiled by Dr. Burrows, clearly exhibits the progressive ratio of apo- 
plexy with advancing age. 







£ 


d 


© 

co 


d 


d 

00 


d 

00 


% 


OBSERVERS. 


CO 


s 


o 


o 


o 


_o 


t> 






o 










© 


M 


H . 




3 


§ 


^H 


o 


CO 




< 


• 


Dr. Abercrombie 


3 


4 


6 


7 


7 


1 





28 


Dr. Bright 


4 


4 


8 


4 


5 


1 





25 


Dr. Andral 


3 


3 


4 


6 


5 


1 





26 


Dr. Rochoux 


2 


8 


7 


10 


23 


12 


1 


63 


Dr. Hope 


2 


2 


9 


6 


7 


11 


2 


39 


Dr. Burrows 


2 


9 


6 


8 


7 


1 


1 


34 


Total in periods of 10 years, 


16 


30 


40 


41 


54 


30 


4 


215 



This corresponds in the main with the results obtained from the Re- 
gistrar General's reports. To explain the apparent diminution after 
the age of seventy, we must remember that the total number of living 
is very much reduced, and that hence the relative number of apoplectic 
cases is probably even larger than at an earlier age. 

The amount of hemorrhage varies from a spot of the size of a pin's 
head to an accumulation of many ounces ; the former, which may be 
termed capillary hemorrhage, is frequently observed in connection with 
effusions of a more extensive character, but may often be assumed to 
have occurred during life, where trifling apoplectic symptoms have 
rapidly passed off under appropriate treatment. It is not generally 
easy to trace the vessels from which the blood has been effused, and 
there is also much obscurity as to the actual nature of the morbid action 
which induces the hemorrhage. All parts of the encephalon m?ij pre- 
sent apoplectic effusions, but the parts most frequently affected are the 
anterior lobes, and especially the vicinity of the corpora striata. As a 
rule, the gray structures, including the convolutions of the brain, ex- 



HEMORRHAGE. 



251 



hibit the greatest proclivity to the affection, which is in consonance 
with the known vascularity of these tissues. The structures most 



Fig. 124. 




Apoplectic effusion upon the left side of the pons varolii. 

removed from the gray matter, as the corpus callosum and the fornix, 
are least liable to it. Apoplectic effusion is not very frequent in the 
cerebellum, but it is found to be more rapidly and invariably fatal when 
it occurs here than elsewhere. Andral's extensive sphere of observa- 
tion has only presented him with six cases of hemorrhage into the 
cerebellum, and in three of these it was associated with hemorrhage 
into the cerebrum. In the causation of apoplectic effusion three ele- 
ments come into consideration; the condition of the blood, the state of 

- Fig. 125. 




Hemorrhage into the right lateral ventricle and right hemisphere, in a man aged 65. He was Drought 
into St. Mary's Hospital in a state of profound coma, and died two hours after admission. There was a large 
ragged cayity in the hemisphere, communicating with the yentricle, from which about 4 oz. of black fluid 
blood escaped. The corpus striatum and thalamus opticus of right side were much softened. There was no 
apparent disease of the arteries. 

the coats of the vessels and that of the tissues surrounding them. The 
first, though the most important, as necessarily influencing most mate- 



252 EEMOKKHAGE. 

rially the two latter, we do not as yet possess sufficient data to speak 
otherwise than hypothetically of. It is not difficult to conceive that 
stasis in individual vessels, the formation within them of exudation 
matter, or an alteration in the density of the liquid, may mechanically 
and vitally influence the origin of this morbid state. The fact of the 
occurrence of sanguineous effusion, as a sequel of renal or cardiac dis- 
ease where no disorganization of the brain is traceable, is a further 
point corroborative of the position. We may also mention that Messrs. 
Andral and Gevarral are of opinion that an essential connection exists 
between cerebral hemorrhages and a diminution in the amount of fibrin 
in the blood with an increase in the quantity of blood-globules. In 
eight venesections, performed upon seven apoplectic subjects, they found 
the fibrin below the normal standard in five, and the globules above it in 
four cases. With regard to the coats of the vessels, the influence of 
chronic arteritis in causing pulpy softening or in giving rise to calcareous 
or atheromatous deposits, and thus rendering them unfit to bear the 
pressure of the blood-current, is a subject of frequent observation, 
though disease of the bloodvessels is not a necessary accompaniment of 
apoplectic effusion. In the same way as this pathological condition 
induces local affections in the thoracic and abdominal viscera, it causes 
aneurisms or ossifications of the arteries of the brain, and in both in- 
stances affects nutrition, and is liable to be followed by rupture and the 
effusion of blood. Such alteration in the nutrition of the nerve-tissue 
as diminishes its resistance to the impulse it receives from the san- 
guineous current, is the third element to which we have alluded. We 
shall consider the main characters of softening more in detail further 
on ; but it is necessary to mention here that it occurs in two forms, 
which appear to be essentially different, the one being due to a state of 
hypersthenia or active inflammation, the other to an impaired or cachectic 
nutrition of the tissue. We cannot always in the dead subject demon- 
strate the sequence or the relation which these conditions bear to one 
another; but an extended knowledge of morbid processes elucidated by 
vital dynamics, the microscope, and animal chemistry, will undoubtedly 
clear up many difficulties connected with cerebral disease, as it has 
already done in diseases of other organs. 

In the present state of our knowledge, and of physical examination, 
the proximate causes of cerebral apoplexy frequently elude the inquirer ; 
but it is difficult to assume that it can occur without previous disease 
within the cranium of the nerve-matter, as well as of the vessels ; the 
fact that apoplectic effusion is not met with in healthy individuals who 
have died from strangulation, alone affords sufficient evidence that a 
mere arrest of the current of the blood is incapable to produce it ; for 
in these cases the vertebral arteries may fairly be assumed to convey 
blood to the brain after its return by the veins has been arrested. 

The apoplectic effusion is not necessarily fatal in proportion to the 
amount of blood discharged from the vessels ; but the rapidity of the 
issue appears to bear a relation to the vicinity of the hemorrhage to the 
medulla oblongata. The effusion of blood into the ventricles is also 
marked by being very rapidly fatal. Much, probably, also depends upon 
the amount of laceration of the cerebral tissue accompanying the hemor- 



HEMORRHAGE. 253 

rhage, inasmuch as the curability of apoplectic effusions seems to be in 
the ratio of the interstitial character of the discharge. Thus, Messrs. 
Foville and Ollivier have pointed out, both with regard to the encepha- 
lon and the spinal cord, that the cure of paralysis resulting from rupture 
of the nerve-tissue is never complete ; but that where the patient is 
restored to perfect health, the hemorrhage has mostly separated and 
compressed the cerebral or spinal fibres. 

The processes that occur in the blood itself, after it has been effused 
within the brain, are: the formation of a coagulum, the gradual absorp- 
tion of the fluid parts of the blood, the formation of an organized mem- 
brane around the clot, and the continued absorption of the latter. The 
rapidity with which these changes occur differs considerably, and depends 
greatly upon the healthy condition of the surrounding parts. Thus, 
while Dr. Macintyre 1 has recorded a case of apoplexy, in which, thirteen 
days after the seizure, the cyst was found fully formed, organized, and 
nearly empty, a French physician, Moulin, 2 mentions one of seventeen 
years' duration, in which a cyst was found containing four ounces of 
sanguineous fluid. When the effusion occurs in the cavity of the arach- 
noid, we have seen that cysts also form, but we do not meet with them 
in the cavity of the ventricles, though there is reason to suppose that 
the blood may be absorbed from their surface also. According to the 
degree of absorption, the clot changes its consistency and color. The 
clot first assumes a deeper color and becomes of a chocolate hue, and, 
from absorption of the serum, is rendered hard ; the coloring matter is 
more and more absorbed, a light-colored fibrinous mass is then seen, 
much contracted from the original dimensions of the clot, and finally 
this too may disappear, leaving no remains of the hemorrhagic effusion 
but the contracted empty cyst, the walls of which are frequently con- 
nected by fibrous beads. The cyst itself, in its turn, shrinks up, and 
finally nothing may remain but a cicatrix. The hsematoid crystals, first 
discovered by Sir Everard Home, and more recently described by Vir- 
chow, are occasionally found in apoplectic clots, together with orange- 
colored granular matter. Virchow 3 states that the earliest period at 
which he has discovered them was seventeen days after the injury; their 
not occurring in recent effusions has been urged as a positive proof 
regarding the age of a clot. 

It is manifest that no effusion can take place into the cerebral tissue 
without a certain amount of disruption of the nerve-matter, portions of 
which may be generally traced within the fresh clot ; the greater the 
previous cerebral softening, the more we shall find the brain comminuted. 
The danger to life, as the recorded cases teach us, is in proportion to 
their cerebral disorganization ; for the tax made upon the powers of the 
constitution, to repair the injury done, is necessarily greater, the more 
inflammatory reaction is set up ; for, though the clot possesses in itself 
a tendency to form a cyst without inflammation, and thus aids in the 
process of reparation, this cannot suffice to repair the injury done to the 

1 Report of Pathol. Society, 1847, p. 11. 

2 Traite" de l'Apoplexie, ou Hemorrhagic Cerebrale, &c. Paris, 1819. 

3 See an article on Blood-Crystals, by Dr. Sieveking, in the British and Foreign Medico- 
Chirurgical Review, Oct. 1853. 



254 WHITE SOFTENING — CEDEMA. 

cerebral tissue. After the absorption has come to a stand-still, the cyst 
or the cicatrix may be borne for years without exciting any new symp- 
toms; and thus, if the individual has suffered from a repetition of apo- 
plectic attacks, we shall find one or more such residuary appearances, in 
a state indicative of the period from which they date. As we occasion- 
ally meet with a recent apoplectic effusion that has been effected near 
the surface of the brain, marked by fluctuation, we find, after the 
absorption of the fluid, a slight depression in the superincumbent nerve- 
tissue, or a supplementary effusion of serum into the ventricles. 



WHITE SOFTENING — CEDEMA. 

The converse of the condition which we have just been considering, 
ansemia, is undoubtedly one of considerable importance, and one that 
may be assumed to be the cause of numerous morbid conditions ; but 
we have a still greater difficulty of determining its existence than that 
of congestion of the brain. Where it exists, the brain presents a 
generally pallid appearance, and especially the white matter is re- 
markably deficient in red spots, and more dead-white than normally. 
It is an important element in the diseases termed white softening and 
oedema of the brain, which, therefore, especially as in their turn they 
may give rise to apoplectic effusion, may appropriately be treated of in 
this place. 

In estimating the degree of white softening, it is important to bear 
in mind the physiological variations in the density of the brain, accord- 
ing to the age of the individual. 1 It is naturally very soft in infancy, 
and progressively becomes firmer with the advance of years ; and, in 
old age, as we find a tendency to rigidity of the soft tissues, and to 
ossification of the cartilages, we discover the brain to present the 
physiological extreme of density and toughness. The diminished 
density of a portion of, or the entire brain, constitutes the disease in 
question ; at times, it appears to be due to an increased infiltration of 
serum, in the cerebral tissue, in which case it may be considered as 
identical with oedema. It is common in children, complicated with 
hydrocephalus, or as a product of arrested or perverted nutrition, or 
exanthematic fevers ; the affected portions of the brain often being 
entirely diffluent. In adults, it is found in connection with phthisis. 

White softening is characterized by a loss of cohesion, varying in 
degree, and is chiefly met with in the parts most remote from the gray 
matter, as one would expect, if the etiology, as given above, is correct, 
because they are provided with fewer bloodvessels. Rostan, who was 
the first to draw attention to cerebral softening, which has since been 
extensively studied by pathologists, admitted the presence of an in- 
flammatory and a non-inflammatory form ; but we owe to Gluge and 
Bennett the means of discriminating the two with physical accuracy, 
inasmuch as they have shown, that an essential feature in inflammatory 
affections of the brain is demonstrated by the microscope. The in- 

1 See a paper by Dr. Sankey on the Specific Gravity of the Brain, in the British and 
Foreign Medico-Chirurgical Review, Jan. 1853. 



INFLAMMATION. 255 

flammation corpuscles or cells, produced by the disintegrating changes 
which accompany the phlogistic process, are invariably found in the 
cerebral tissues, where there is inflammation; and it is characteristic of 
the non-inflammatory softening, and of cedema of the brain, that these 
corpuscles are not met with. The microscope only exhibits the mere 
debris of nerve-tissue, in a state of greater or less destruction, without 
any trace of new formations or products. The entire absence, then, of 
inflammation corpuscles in a softened portion of brain, serves to confirm 
the opinion of its non-inflammatory character. According to Dr. 
Todd, 1 white softening is characterized by organic globules, or large 
cells, containing oily matter, from which he infers that the disease is 
accompanied by an active process during life, although he regards it 
essentially as an atrophic condition. Abercrombie and some other 
writers attribute the form of softening just described, under the term 
of cerebral softening, to inflammation ; an analysis of the cases given 
by Abercrombie himself, will be found to support the view of the exist- 
ence of white softening without the physical signs of inflammation. 
The microscopic discovery of the product of inflammation will, in 
future, aid the pathologist in determining the question in individual 
cases. 

(Edema of the brain is a common condition of the organ met with 
in ataxic conditions, such as typhus, or puerperal disease, in exanthe- 
mata, heart disease, and anasarca. It is common in insanity. Pinel 
describes it as the pathological condition characteristic of stupor, or 
acute dementia. He states, 2 that if the medullary tissue of an oede- 
matous brain be torn, a peculiar feature presents itself; at the summit 
of each rent, and at the angle formed by the separation of the fibres, 
whitish filaments may be perceived with the naked eye, which are 
nothing but capillaries, strongly injected with serosity ; they pass from 
side to side, and when torn, allow a small quantity of serosity to es- 
cape; in the normal state, these capillaries are filled with colored blood. 
On cutting into a brain thus affected, the tissue is found pallid, and the 
water drips from it, showing a complete oedematous imbibition. The 
infiltration causes an enlargement of the brain, and consequent flatten- 
ing of the convolutions. 



INFLAMMATION. 

We now return to the examination of one of the sequelae of conges- 
tion, which, in some of its forms and products, constitutes a class of 
very fatal diseases. Inflammation of the brain occurs in the various 
forms, and gives rise to the same products that we find in other organs, 
modified, of course, in their characters by the anatomical relations of 
the organ. We find it as an acute and as a chronic disease. Acute 
inflammation of the brain is not frequently met with in the dead-house, 
in the early stages, nor is idiopathic encephalitis a disease of common 

1 Clinical Lectures on Paralysis, &c, 1854, p. 99. 

2 Traite de Pathologie Cerebrale, p. 257. 



256 



INFLAMMATORY SOFTENING. 



occurrence, and many of the cases recorded by older writers resolve 
themselves into cases of meningitis. It is not our province to inquire 
into the causes of the peculiarities of diseased action; but we may 
allude to the circumstance of the brain being so completely withdrawn 
from physical influences acting immediately upon it, as one of the 
reasons why idiopathic inflammation should not set up in it, with the 
same frequency and violence that it exhibits in organs that are more 
exposed. It is brought on by exposure to the sun's rays in hot sum- 
mer days or in tropical climates, and may be so rapidly fatal as to pro- 
duce death before the purulent stage has supervened. Other instances 
of idiopathic encephalitis are, however, met with in the early stage, in 
which no such direct exciting cause is traceable. In a case of this kind 
we find a more or less circumscribed dusky redness in the substance of 
the brain ; the spot generally occupies the upper part of the hemi- 
spheres, and, on section, drops of blood may ooze out from the divided 
surface: there is no necessary change in the consistency of the spot, 
though it is frequently somewhat softer than the healthy tissue ; as the 
disease advances, the exudation of lymph and suppuration ensue, and 
the color and consistency of the affected part are modified in propor- 
tion. These products are much more frequently the result of chronic 
and of secondary, than of acute and primary, encephalitis. So much 
so, in fact, that softening, which is the most common effect of inflam- 
matory action, has been treated, by many authors, as an idiopathic 
disease. 



INFLAMMATORY SOFTENING. 



The consistency of cerebral tissue may be altered by inflammatory 
exudation alone, or with the supervention of suppuration. In the 

Fig. 126. 




VcBsels f;o n the brain of a female aged 40, who died hemiplegic, in consequence of red softening of the 

right hemisphere. 

foimer case, we shall find traces of congestion, giving to the affected 
part a reddish hue; and in the softened tissues, the microscope will 



INFLAMMATORY SOFTENING. 257 

show, besides broken-down nerve-matter, a large number of exudation 
corpuscles ; while, as soon as suppuration has occurred, there is a change 
of color, and we may expect to find pus-cells in addition to the former. 
Exudation matter may, however, be found where there is no perceptible 
change in the consistency of the tissues, or other palpable lesion, and 
it is here that we feel the great advantage of the microscope in assist- 
ing our views on the pathology of disease, because it often serves to 
account for symptoms that otherwise are not to be explained. The 
vessels, especially, appear covered with, or to contain, the molecules of 
exudation matter, without the presence of the exudation corpuscles and 
masses, which are evidently a further stage in the exudation process. 
The absence of pus-cells would not be an absolute proof that suppura- 
tion had not occurred; for they are not always present 1 in undeniable 
abscesses, where molecular granules and pyoid bodies may be the sole 
objects detected by the microscope. We are further borne out in this 
view by Dr. Bright, 2 who expressly states that we can hardly restrict 
the term, abscess of the brain, to those very rare cases in which well- 
formed pus is found in the substance of the cerebral mass. 

Suppuration occurs in three forms : we find it occupying the convo- 
lutions in the shape of a ragged ulcer, varying in size from a fourpenny 
p\ece, or less, to that of half a crown ; or the pus is infiltrated through 
a large extent of cerebral tissue, causing what Dr. Bright terms the 
diffused abscess ; or again, the pus becomes limited, as in other parts of 
the body, by a membranous expansion, and we then have to deal with 
the encysted abscess. The consistence and color of the parts in which 
exudation and suppuration have been effected, vary according to the 
extent to which the tissues are involved; the softening may be scarcely 
sufficient to mark a difference between the healthy and the diseased 
portions, and it may reach such a degree that the latter are perfectly 
diffluent; the discoloration, in the same way, will be more or less straw- 
colored or reddened, according to the amount of suppuration, the injec- 
tion of the bloodvessels, and the accompanying exhalation of blood, or 
its coloring matter. We have already alluded to the presence of exuda- 
tion corpuscles, which are detected by the microscope in inflammatory 
affections of the encephalon. They will here be found in large num- 
bers, and will assist in establishing our post-mortem diagnosis, in 
addition to the evidence, afforded by the microscope, of the presence 
of true pus-corpuscles. The necessary disorganization of the cerebral 
tissue, which must ensue in each of these cases, causes the presence of 
broken-up nerve-matter, which the microscopic specimens will be found 
to contain. When we have to do with red or apoplectic softening in 
which hemorrhage has occurred, we shall also detect blood-corpuscles 
in a more or less altered state. A rough way to determine the presence 
of softening is, to allow a gentle stream of water to fall upon the sus- 
pected part ; the softened parts will more or less readily give way and 
break up. 

1 Lebert, Physiologie Pathologique, vol. ii. p. 303. 

2 Reports, p. 171. See also Bennett on Inflammation of the Nervous Centres, Edinb. 
Med. and Surg. Journal, 1842-43. 

17 



258 INFLAMMATORY SOFTENING. 

With regard to the locality of red or inflammatory softening, authors 
are not agreed as to the preponderance of its occurrence in the gray or 
the white matter ; while Gluge and Durand-Fardel are of opinion that it 
is more frequently met with in the former, Dr. Bennett's researches 
lead him to assert, that the white matter is the chief seat of this morbid 
action. French physicians look upon softening of the superficial 
laminae of the convolutions as peculiar to dementia, and state that it is 
characterized by portions of the gray matter adhering to the meninges 
when they are removed. 

It follows, from what we have stated, that some of the distinctions 
which authors have laid down with regard to the varieties of softening, 
as characterized by their color, are not essential differences, but rather, 
different stages of the same inflammatory process. The structure of 
nerve-matter would, a priori, lead us to expect that the products of 
inflammation would assume an appearance different from what they 
present in other tissues of the body, and as we advance in our know- 
ledge of cerebral disease, we shall probably succeed in reducing it still 
more to the general type of morbid action. Dr. Abercrombie has sug- 
gested that ramollissement of the cerebral substance is analogous to 
gangrene, occurring in other parts of the body; but, though obliteration 
of the small arteries of the brain may give rise to this change, it is by no 
means an essential cause; and we may sum up the prevailing views on 
the subject, in Dr. Bright's classification of the causa proxima of soften- 
ing ; he attributes it — (1) to an impediment in the circulation ; (2) to 
congestion ; and (3) to inflammatory action. The reader will gather 
from our remarks, that we do not concur in the view of Dr. Aber- 
crombie ; an additional argument against it is, that aneurism of the 
cerebral arteries is not commonly followed by softening ; and, if any- 
where, we should expect to find it in this case most uniformly, if the 
process is identical with death of the part. Those cases of ramollisse- 
ment which we have attributed to mal-nutrition, or a cachectic state of 
the blood, as opposed to those resulting from inflammation, would be 
more appropriately classed under the head of gangrene ; and under this 
head may also be placed the cases of softening resulting from ligature of 
the carotid artery; but we are not justified in assuming the presence of 
gangrene in parts which, though seriously diseased, are by no means 
withdrawn from the range of vital processes. An important physical 
symptom of gangrene is remarkably absent in softening of the brain, 
viz : a fetid odor. 

Softening of the brain is looked upon as an essentially fatal disease, 
though there is no inherent reason why the process of resolution and 
absorption should not be carried out within the brain as in other organs. 
It is probable that, as our means of diagnosis become more perfect and 
more refined, our knowledge of this subject will also enlarge; at present, 
we deal rather with the last stages of the disease than with its incipient 
and more curable features. One reason why inflammatory softening 
appears less tractable than analogous processes elsewhere, is that the 
brain does not possess a great power of isolating the disease ; encysted 
abscess is a very unfrequent occurrence in cerebral pathology. The 
greater number of cysts containing pus, that we meet with, are the 



INDURATION — HYPERTROPHY. 259 

result of external injury, involving the bone, as if nature only cared to 
protect the brain from contact with the external atmosphere. It was 
already observed by Dr. Baillie, that abscess on the surface of the 
brain was almost constantly the effect of external violence, but that it 
was often independent of this cause when formed at a considerable 
depth within the brain, and that the former was by far the more com- 
mon form. The cyst itself presents in either case various degrees of 
thickness and density ; the former may amount to half a line, and the 
latter increase to the consistency of leather. The cysts themselves 
have a laminated fibrous structure, and they are lined with a layer of 
the pyogenic membrane. 

With regard to the cause of softening, as of cerebral disease gene- 
rally, it must be mainly sought for in changes directly and primarily 
affecting the brain ; but that peripheral affections may be followed by 
central disease, is forcibly illustrated by the case published by Lalle- 
mand 1 of a soldier, who had been operated upon for aneurism of the 
right axillary artery. In applying the ligature, the nerve was inclosed, 
cerebral symptoms followed on the seventh day, and death ensued on 
the eighth : the post mortem showed an abscess in the left posterior 
cerebral lobe. The case is also of interest, as affording proof of the 
uniformity of the law of crucial conduction. 

In phlebitis and purulent infiltration, which are commonly associated 
with cerebral symptoms, we do not generally discover any marked trace 
of disease in the brain. Metastatic abscesses appear limited to the great 
organs of depuration ; but while we rarely, if ever, discover metastatic 
abscess in the brain, in consequence of phlebitis in other parts of the 
body, it is not uncommon to find metastatic abscess in the liver or spleen, 
after idiopathic phlebitis in the veins of the brain. 



INDURATION — HYPERTROPHY. 

The converse of ramollissement or induration, appears, like the 
former, to be an occasional result of a phlogistic process ; but, like it, 
we must in many instances attribute it to a non-inflammatory change in 
the nutrient sphere. We find portions of the brain both at the surface 
and in the deeper-seated parts presenting no material alteration beyond 
an increased density as compared with surrounding parts. This is dis- 
tinct from the hardened cicatrices resulting from the absorption of 
apoplectic effusions. A general hardening of the brain, accompanied by 
a livid earthy hue, and an increase of the entire volume of the organ, 
is met with in chronic lead poisoning ; 2 the convolutions are found 
flattened, the ventricles are compressed, the tissue is dry ; and a chem- 
ical analysis will detect the presence of sulphate of lead in the brain. 
Tanquerel des Planches records two cases in which this was done. It 
is also found in cases of acute lead poisoning. 3 A similar state of in- 

1 Recherches Anatomico-patkologiques sur l'Encephale, &c, vol. i. 123. 

2 Tanquerel des Planches, Traite des Maladies de Plomb, Paris, 1839, vol. ii. p. 298. 

3 Alfred Taylor on Poisons, &c, p. 133. 



260 INDURATION — HYPERTROPHY. 

duration and hypertrophy of the white substance, is stated by Ferrus 
and Parchappe to be found in epilepsy. Laennec and others have also 
directed attention to hypertrophy as simulating hydrocephalus. We 
must also be careful not to confound cases of tumefaction of the brain 
from softening with hypertrophy ; thus we find, in Andral's Clinique 
Jledicale, the account of a post-mortem, in which, owing to this cause, 
the left hemisphere was so much swollen as to push over the mesial line 
to the left side. A similar instance is preserved in the museum of St. 
Thomas's Hospital. 

In a case of hypertrophy, on removing the skull-cap, the brain seems 
to expand, as if it had been previously confined in too narrow a space ; 
the membranes are thin, the convolutions are flattened by being com- 
pressed against the bone, and the ventricles are found to contain very 
little or no fluid. On making a horizontal section, the gray matter is 
not seen altered, and the naked-eye view displays an increase in the 
amount of white matter ; this, according to Rokitansky, is owing, not 
to an augmentation in the number of nerve-tubes, or their dimensions, 
but in the excessive accumulation of the intervening and nucleated sub- 
stance. We have not ourselves been able to confirm this statement, 
nor have we found corroborative evidence in other writers. Hypertro- 
phy appears to be due to a lymphatic constitution, and it is met with 
chiefly in early childhood. As long as the fontanelles are not closed, 
it does not in itself involve danger, and even the intellect continues un- 
impaired ; but as soon as the fontanelles have closed, the undue pressure 
gives rise to numerous cerebral symptoms, none of which, however, are 
characteristic of this disease. It belongs essentially to the family of 
scrofulous affections ; the frequent coincident distortion of the bones, the 
swelling of the lymphatic glands, and the general torpor of the system, 
suffice to establish its relationship. The bloodlessness and dryness of the 
tissues must assist us in deciding, in a doubtful case, whether we have to 
deal with hypertrophy of this character, or with hyperemia, hydroce- 
phalus, or oedema, conditions which also may cause the brain to appear 
too large for its case, and produce a flattening of the convolutions. 
Nor would it be just to consider as diseased a brain, which, though 
larger than the average at the age of the individual, exhibits no morbid 
relations such as those described. 

Individual parts of the cerebrum are very rarely found hypertrophied 
by themselves. Dr. Mauthner 1 records a case of hypertrophy of the 
thalamus opticus of the right hemisphere in a child of three years of 
age, which, till within three weeks of its death, had enjoyed sound 
health. She then fell from her chair, striking the occiput, and became 
paralyzed on the left side. Shortly before death scarlet fever super- 
vened, she became delirious, and died comatose. The thalamus is de- 
scribed as enlarged to the size of a hen's egg, of a lardaceous, dead- 
white appearance on section, without softening of _ the adjacent parts or 
'.'ifusion ; except that the testes were very vascular and the left optic 
nerve enlarged, no abnormity was discovered. Dr. Mauthner is of 

1 Die Krankheiten, des Gehirns, unci Ruckenmarks, bei Kindern, von L. W. Mauthner. 
Wien, 1844, p. 189, 



ATROPHY. 261 

opinion that the organic malady had remained latent, until the occur- 
rence of the fall. The same author gives an interesting table, showing 
the weights of the brains of fifty children aged fifty months and under, 
who died of various diseases; he concludes that all inflammatory affec- 
tions have a tendency to increase its weight, and that this increase is 
mainly due to the greater amount of blood contained in the cerebral 
vessels. 



ATROPHY. 

The converse of hypertrophy is a condition which, as we have already 
had occasion to remark, is the result of a natural process in old age; 
but it is also the effect of disease ; or of an arrest of development. In 
consequence of long-standing, exhausting illness in children, Dr. West 
informs us that the brain is found far from filling up the cavity of the 
skull, so that a knife may be passed, in many places, between it and the 
cranial walls. The same appearance is met with in the adult, and the 
consequence is that serum is effused between the brain and its envelops, 
in order to supply the defect ; the convolutions become thinner, and they 
are separated by broader sulci. There is some discoloration of the tissue, 
and the veins of the pia mater are observed to present a varicose ap- 
pearance, owing to the loss- of the support which they experience. We 
also meet with partial atrophy ; this is generally of a secondary character, 
owing to pressure exerted upon individual parts by tumors or other ad- 
ventitious growths, apoplectic cysts in the arachnoid or peripheral lesions. 
The absorption induced by the effect of pressure is accompanied by in- 
duration of the adjoining layers of the cerebral tissue. The atrophy 
that is found as a result of arrest in the functions of a peripheral nerve, 
as in the case of the optic thalamus in amaurosis, is a marked instance 
of the influence of functional derangement upon nutrition, propagated 
to a distance. 

In idiots, we have congenital atrophy of the entire, or of portions of 
the brain ; in the brain of old insane persons it is common, according to 
Neumann's statement, who has examined fifty cases of the kind, to find 
the posterior lobes and their convolutions more atrophied than other 
parts; Sir Charles Bell, Cruveilhier, and Lallemand record cases of 
epilepsy and hemiplegia, accompanying congenital atrophy of one hemi- 
sphere, though not necessarily associated with a destruction of the in- 
tellectual powers. 



CHAPTER X. 

THE BRAIN— MORBID GROWTHS. 

The products of a perverted state of nutrition and of a cacoplastic 
condition of the blood, which are found in other tissues of the body, 
also occur in the brain, though for the most part in a secondary form ; 
associated with or following upon their deposit elsewhere. They have 
certain features in common, owing to the anatomical relations of the 
brain; thus, they all generally assume a rounded shape, owing to the 
uniform pressure to which they are subjected on all sides; they are not, 
as for instance in the lungs, received into a mould by which their ex- 
ternal configuration is in a measure determined; they do not proceed to 
a similar degree of development from the early danger to life which they 
induce ; they are liable to produce softening of the tissues in the imme- 
diate vicinity, and, owing to the impairment of the circulation, are com- 
monly accompanied by an effusion into the ventricles. The last two 
circumstances are those to which we may probably refer the symptoms 
observed during life ; for the presence of tumors in the brain is often 
not discovered until the death of the patient from disease of some other 
organ, and where they had maintained this quiescent state, the cerebral 
tissue in the vicinity exhibits no traces of degeneration. Thus, Messrs. 
Tonnelley Leveille', and others, who have devoted especial attention to 
the occurrence of cerebral tubercle, conclude that the tubercles in them- 
selves do not give rise to any symptoms, but that the cerebral symptoms 
accompanying them are exclusively due to the intercurrent inflammation. 
The difficulty of early diagnosis, and the fact of adventitious growths in 
the brain occurring almost exclusively in the secondary form, place them 
more especially in the range of the morbid anatomist ; they are even less 
amenable to therapeutic treatment than when they have found a nidus 
in the abdominal or thoracic organs. The form in which we most fre- 
quently meet with them is tubercle and cancer. 



TUBERCLE. 

Tubercle, as we have already had occasion to see, is a frequent con- 
comitant or source of meningeal inflammation. Tubercular deposit in 
the cerebral tissue, like the former, is equally a disease peculiar to 
childhood ; but the two are not necessarily associated together. Tuber- 

1 See Rilliet and Barthez, Traits Clinique des Maladies des Enfants, torn. xiii. 
p. 552, seq. 



TUBERCLE. 263 

cle in the brain may affect any part of the organ; it occurs in the shape 
of rounded nodes varying in size from a pin's head to a walnut or hen's 
egg; the deposits are not generally numerous, and their size bears an 
inverse ratio to their frequency. It is most common to find only one or 
two, and of an average size of a chestnut. Dr. Baly has recorded a 
case in the reports of the Pathological Society 1 of a young man who 
died in the Millbank prison, and in whose brain tubercles were found ; 
only two were discovered in the left hemisphere, but the number in the 
right are estimated to have been as many as fifty, varying in size from 
a grain of pearl barley to that of a barley-corn ; the same case is also 
instructive as showing the great rapidity with which the deposit may 
occasionally take place under circumstances favoring the disease; for 
the patient was admitted into the prison on the 30th December as a 
healthy subject ; after a few days was attacked with headache, and 
on the 19th of January following, he died with all the symptoms of an 
acute cerebral affection. The case appears to disprove the dictum of 
Rokitansky, that cerebral tubercle never occurs in any but the chronic 
form. 

The tubercle presents the appearance and consistency of soft yellow 
cheese, and while miliary granulations are peculiar to the meningeal 
form, the yellow tubercle is the variety almost invariably met with in 
the brain. We are unable to determine whether the deposit takes place 
in this form; the more extended application of the microscope will best 
decide the question ; since the microscopic characters of tubercle are 
sufficiently determined to give a positive answer. Rokitansky is of 
opinion that tubercle in the brain, does, in part at least, commence in 
the gray translucent form, for portions of a tubercular mass are some- 
times found in that state. In any case, however, he adds, it may con- 
tinue for a short period only in that form, and soon pass into the stage 
of the yellow cheesy tubercle. The microscopic elements are the same 
granulated nuclear corpuscles of an ovoid or somewhat irregular shape, 
interspersed with granular blastema and particles of oily matter found 
elsewhere ; according to the amount of inflammatory action exerted in 
their vicinity we shall also find more or less glomeruli, with other traces 
of its effects. The tubercle is generally surrounded by a delicate cyst, 
and when, which occasionally happens, the tubercular matter proceeds 
to the stage of softening, the superficial observer may mistake the morbid 
appearances for those of a simple abscess of the brain. The concurrence 
of tubercle in other parts, together with the aid of the microscope, will 
assist in fixing the real character of the affection. The frequency of 
tubercle of the brain in children is a point not to be forgotten in the 
treatment of their diseases, and is one of the reasons why the overstrain- 
ing of the mental faculties of a delicate child is so much to be repro- 
bated. Physicians who have had the most extensive experience in these 
matters agree as to the rarity of its occurrence in the adult; thus, Cru- 
veilhier never met with a single case, and Lugol, in the large hospital 
of St. Louis, has only seen eight instances, in none of which any symp- 
toms of the disease were manifested during life. 

1 Session 1850-51, p. 34. 



26i CANCER. 

It is a singular fact, which we gather from the statistics of MM. 
Rilliet and Barthez, that sex appears to exert a marked influence 
upon the occurrence of cerebral tubercle ; in each variety, the males 
are considerably more liable to the affection than females ; of forty-four 
cases, we find twenty-nine occurring in boys, and fifteen in girls. The 
fact is confirmed by the statistics of our own medical writers: an ana- 
lysis of fifteen cases reported by Dr. Abercrombie and others, establishes 
a similar proportion; ten of these cases were males, and five females. 
It is, however, right to state that Dr. Hennis Green's 1 statistics con- 
tradict this fact ; his observations were made at the same hospital as 
those of MM. Rilliet and Barthez, and, of the thirty cases which he has 
collected, fourteen occurred in boys and sixteen in girls. 

The deposit of tubercular matter sometimes occurs in patches of irre- 
gular shape and size, on the surface of the brain, beneath the pia mater, 2 
but commonly, as we have already seen, it forms nodules within the 
cerebral tissue. It is often met with both in cerebrum and cerebellum 
at the same time ; the number of cases in which it occurs in one or the 
other alone is about equal ; the pons varolii is, in rare cases, the only 
seat of the deposit. 

In the lungs, we frequently meet with satisfactory evidence of the 
power of the system to reject and cure tubercle ; we are not possessed 
of similar proof with regard to the brain ; the only analogous process 
is that in which the vitality of the deposit seems utterly destroyed, and 
cretification results; this is a metamorphosis which sometimes, though 
rarely, takes place in cerebral tubercle. We must not confound with 
cretification of tubercle, certain gritty or sabulous masses found in the 
brain; thus, our notes contain the history of a case, in which, on a 
vertical section of the cerebellum, the knife grated upon some calculous 
formations, imbedded in the tissue, and intimately adherent to it ; there 
proved to be, on each side, three or four irregularly crystallized masses, 
which broke up easily on pressure, and were not affected by either liquor 
potassse or acetic acid. There was no other perceptible disease of the 
cerebral tissue, but the choroid plexuses were covered with concentric 
corpuscles. Andral 3 gives, as a great curiosity, an analogous case, in 
which, however, the "ossifications" were inclosed in a cyst. 



CANCER 

Next in frequency to tubercular deposit we find the various forms of 
cancer, all of which, excepting the epithelial variety, are met with in 
the brain. There are no symptoms peculiar to the disease, beyond the 
effects resulting from pressure ; and even they do not appear to be in 
any way commensurate with the size of the deposit. The form which 
it assumes is that of infiltration, without any definite limits, or of a 
tumor surrounded by a cyst; in the former case, there seems a con- 
tinuity of tissue between the cancerous mass and the nerve-tissue. The 

1 Medico-Chir. Trans, vol. xxv. p. 192. 

2 See Mr. Dunn's case, ibid. p. 209. 

3 Clinique Medicale, t. v. 719. 



CANCER. 265 

same law, with regard to the predominant liability of the cerebrum 
compared with the cerebellum, applies in the present instance ; thus, in 
forty-three cases of cancer of the nervous centres alluded to by An- 

Fig. 127. 




Cancerous tumor, occupying the upper portion of the posterior cerehral lobe of a man aged 54, brought 
into St. Mary's Hospital comatose and hemiplegic, in which state he remained until death. The central 
portion was dense and fibrous, of a yellow color, and consisting of fusiform fibre-cells : the external portion 
soft, cream-colored, or pink, composed of a variety of compound cancer-corpuscles. The whole was sur- 
rounded by a red vascular margin. 

dral, 1 we find thirty-one occurring in the cerebral hemispheres, and five 
in the cerebellum ; the remainder were thus distributed: three were 
found in the pituitary gland, one in the corpus callosum, and three in 
the spinal cord. The same author, by an analysis of the cases col- 
lected by him, establishes, numerically, the relation commonly found to 
prevail with regard to the frequency of primary cancer in the nervous 
centres ; in ten of the forty-three cases only, or less than one-fourth, 
was there any carcinoma in other organs. As a result of local injury, 
we meet with a species of fungoid growth of the brain, which has been 
termed hernia cerebri, but which is very different from the hernia cere- 
bri to which allusion has been made, in the section treating of congenital 
hydrocephalus. In consequence of a fracture of the skull, the brain 
appears to sprout forth in the shape of a vascular, medullary growth. 
It appears as if the brain, released from its confinement, luxuriated in 
its newly-acquired liberty. Extensive suppuration is generally found 
accompanying this form of hernia, within the brain. We are not in 
possession of any microscopic examination showing the exact nature of 
the growth. 

In addition to tubercular and cancerous deposits we also meet with 
melanotic, fatty, and fibrous growths, and cysts in the encephalon. 

It was long doubted whether melanosis ever occurred in the brain, 
and it certainly is rarely found in this locality. Sir Robert Carswell, 2 
however, gives a specimen of two tumors of this description, which 

1 CliDique Med. t. v. p. 633. 

2 Pathological Anatomy, 1838, Art. Melanoma, pi. ii. 



266 FIBROID TUMORS — CYSTS. 

were located in the right hemisphere of the cerebrum of a man ; they 
were of the size of a hen's egg, and penetrated into the ventricles. 
Melanotic deposits were also found in other organs of the same subject, 
and the veins passing from the tumors in the brain, were observed to 
contain melanotic matter in a fluid condition. Dr. Hooper's work on 
the brain also contains a plate representing this disease ; and, recently, 
Dr. Clendining brought a case of the kind before the notice of the 
Pathological Society. 1 

The simple fatty tumor is only found in the choroid plexus, where it 
does not, however, attain any great size. The fatty growths most fre- 
quently met with in the brain are those which are termed cholestea- 
toma; they are formed of concentric layers, and present a metallic 
lustre ; they consist of membranous layers, ordinary fat-vesicles, and 
cholesterin plates, and are inclosed in a capsule. They attain the size 
of a walnut or goose's egg. 



FIBROID TUMORS. 

We have searched in vain for the evidence of fibrous tumors occurring 
in the cerebral tissues, though their existence is admitted by Rokitan- 
sky. None of the pathological works that we have consulted record a 
case of the kind; we are, therefore, inclined to assume that they are 
limited to the dura mater, and that fibroid tissue only occurs in the 
metamorphosis of old cysts or envelops of the heterologous growths 
found in the brain. 



CYSTS. 

Cysts of various kinds present themselves in the brain ; those resulting 
from apoplectic effusions are the most common, and present, as we have 
seen, various stages of development. It is probable that, in many in- 
stances, their formation may be due to the same process as that described 
by Mr. Prescott Hewett, as giving rise to the inter-arachnoid cysts, viz : 
a formation of a false membrane, subsequent to the effusion from the 
sanguineous clot. The firmness and thickness of these cysts will serve 
to distinguish them, even when they only contain serum, from the true 
hydated cyst. The microscope, by determining the presence of entozoa, 
or the parallel lamination of the envelop peculiar to hydatid growths, 
will further assist our diagnosis. The only parasites hitherto discovered 
in this locality, are the ecchinococcus and the cysticercus cellulose, 
which, however, are not to be viewed as essentially distinct. The 
acephalocyst occupies the peripheral, more frequently than the central 
portions of the hemispheres, and is found to present no connection with 
the surrounding tissues. When met with in the brain, there is gene- 
rally a coincident development of the same parasites in the liver, a fact 
first pointed out by Aran, 2 who has analyzed forty-seven cases of 
this kind. 

1 Report of the Pathological Society of London, 1847, p. 15. 

2 Schmidt's Jahrbiicher der Medicin, vol. xxxiii. p. 136. 



THE P1TUITAKY BODY. 267 



THE PITUITARY BODY. 



The pituitary body presents morbid conditions, which, generally, are 
rather pathological curiosities, than that they offer any peculiar points 
of general interest ; in a physiological point of view, tumors or cysts 
occurring in it attract attention, from their not producing those symp- 
toms which are generally attributed to pressure upon the encephalon, 
and this is supposed to be due to the force acting in an upward direc- 
tion. Thus, they are rarely accompanied by paralysis, though acquiring 
an extent sufficient to displace the lateral ventricles with the thalami 
and corpora striata, a circumstance presenting, as Dr. Romberg remarks, 
an analogy to the different effect produced upon the conduction of a 
nerve by a tumor, according as the nerve is gradually distended or forci- 
bly compressed. Neither Rokitansky, who treats diseases of the pitui- 
tary body in detail, nor Engel, who has written a monograph on the 
subject, corroborates the observations of Joseph Wenzel, that disease of 
the pituitary body is an essential feature in epilepsy. The pathologists 
of our own country have not observed a relation of the kind. Epilepsy 
is met with as a result of the most various degenerations, or morbid pro- 
ducts within the brain, independently of any marked disease of this ap- 
pendix cerebri ; it is not constantly associated with any one lesion, and 
in the cases of disease of the pituitary gland, given, for instance, by Dr. 
Bright, we find no epileptic seizures during life ; or, conversely, we see 
epilepsy 1 occurring without any disorganization of this part. 

The pituitary body does not seem to bear any definite relation to the 
manifestations of the mind. Dr. Bright 2 gives an instance in which it 
was absent ; the patient was a man who died at the age of forty-eight, 
of softening of the left corpus striatum; but he had enjoyed thorough 
good health until five months previously. 

In the course of our account of cerebral morbid anatomy, we have had 
occasion to allude to the occurrence of aneurism of the cerebral arteries: 
the subject will meet with a fuller consideration when we treat of the 
diseases of the vascular system ; but we could not dismiss the pathology 
of the brain without pointedly remarking upon their importance in the 
production of cerebral symptoms, and as a more or less direct cause of 
death. The diseases of the arteries play a most important part in the 
production of cerebral disease, and in many of the morbid conditions 
which we have passed in review they may be viewed as one of the main 
elements. 

1 Reports, &c, case cxlii. 

2 An interesting case of disease of the infundibulum and pituitary body is given in the 
records of the Pathological Society of London for 1849, p. 19. 



CHAPTER XI. 

THE SPINAL CORD AND ITS MEMBRANES. 

We must commence this section with the ungratifying confession that 
it is a subject upon which our knowledge is very limited. This is partly 
owing to the various baseless hypotheses which the pathology of the spinal 
cord has admitted, and still more to the mechanical difficulty which pre- 
sents itself to the investigation of its derangements, during life, as well 
as after death. The depth of muscle which invests the spinal column on 
the dorsal surface, the tediousness of the procedure of sawing through 
the arches of the vertebrae, and the routine system of conducting post- 
mortem investigations, militate against the frequent examination of this 
organ. Nor can we hope that any great amelioration will take place in 
this respect, until our hospitals and medical schools are able to endow 
the curatorships of morbid anatomy in such a manner as to secure the 
undivided services of men of science, for a series of years. So long as 
the spinal cord was considered only as an aggregation of nerve-fibres, 
serving to conduct influences to or from the brain, it was natural that its 
pathological changes should be regarded as of a secondary importance ; 
but since the researches of Dr. Marshall Hall have shown its claim to 
be considered in the light of a central organ of the nervous system, en- 
dowed with powers independent of the brain, the morbid anatomy of the 
spinal cord has also acquired a higher dignity. As our knowledge of its 
physiological endowments, and of its structure, is enlarged, and as our 
means of physical diagnosis are improved, we may hope to see its morbid 
anatomy better understood and appreciated. At present, we can scarcely 
be said to have advanced beyond the very threshold of this department 
of science. 

We shall follow the same order we adopted in treating of the morbid 
anatomy of the brain, and examine successively the post-mortem appear- 
ances of the dura mater, the arachnoid, and pia mater, and then of the 
cord itself. In all cadaveric examinations of the spinal column, it is 
particularly to be borne in mind that the position of the body after death 
may influence the post-mortem phenomena, independently of morbid 
action, owing to the gravitation of the fluids to the depending portions, 
and their secondary effect upon the nerve-tissues. How important it is 
to attend to this point, is illustrated by some observations, made by Mr. 
Curling, 1 of tetanic cases. On examining the body of a man who had 
died of tetanus, which had been placed on its face immediately after 
death, Mr. Curling found that part of the pia mater covering the ante- 
rior columns of the medulla spinalis remarkably vascular ; a circum- 

1 On Tetanus, p. 48. 



THE SPINAL CORD AND ITS MEMBRANES. 269 

stance which would necessarily induce a conviction in the mind of the 
pathologist, that an essential lesion had been discovered, by which the 
exaltation of motor action could be satisfactorily explained. Unfortu- 
nately for the conclusive force of the observation, in three other instances, 
where the bodies were suffered to remain in the usual position, the vessels 
on the posterior parts only were observed to be turgid. 

This influence of position is more likely to affect the spinal cord than 
the brain, owing to its being less excluded from atmospheric agency. It 
is also important to remember that the relation of the envelops of the 
cord differs from that existing between the investments of the brain and 
their contents in various material points. The movements of the osseous 
case of the cord would have rendered a close adhesion with the mem- 
branes a source of frequent danger; we may fairly assume this as a 
reason why the dura mater of the spinal column is only very loosely 
attached to the vertebral canal ; on which account it allows of an accu- 
mulation of fluid on its external surface, such as we but rarely meet with 
in the brain. Owing to the firm attachment of the dura mater to the 
occipital foramen, fluids accumulated on this part are prevented passing 
into the cranial cavity, while there is a free communication between the 
arachnoidal spaces of the two cavities. This fact is one that must not be 
overlooked in morbid affections both of the spine and the encephalon ; 
independent of the protection that the arachnoidal fluid affords to the 
cord, it is an evident means of securing a balance in the circulation in 
the nervous centres, while, on the other hand, a derangement in its 
quantity and site may be alone sufficient to produce serious symptoms, 
which the morbid anatomist would be unable to measure by physical tests. 

We possess no evidence of the occurrence of idiopathic disease of the 
spinal dura mater, though it can scarcely be supposed that a fibrous 
membrane, situated as it is, should not suffer from the rheumatic dia- 
thesis. In all cases of injury of the vertebral column it is liable to be 
affected, and scrofulous disease of the vertebrae and the extension of 
psoas abscess may involve it. In the congenital affection termed spina 
bifida, which is analogous to the form of hernia cerebri, occurring in 
infants as a result of non-closure of the cranial bones, the dura mater 
extends into the cyst that shows on the dorsal surface of the column ; 
but it is occasionally found deficient at one point, so that the contained 
fluid is only retained by the thin meninges. This pathological state 
differs from that to which we have compared it in this, that the fluid is 
entirely external to the nerve-tissue, and that the cyst at no time pre- 
sents a layer of medullary matter. 

The tumor varies in size from that of a small nut to that of a child's 
head; it generally is solitary, and occupies the lumbar or sacral region; 
when occurring in the back we may expect to find another tumor of the 
same description lower down. The swelling is of a semi-globular, or 
ovoid shape, and may appear pediculated, owing to a constriction at its 
base. The thinness of the cutaneous covering passing over the tumor, has 
induced some pathologists to deny its presence; this however is an error. 

The rarity of the occurrence of idiopathic diseases in the dura mater, 
applies equally to adventitious products. Encephaloid, and other forms 
of carcinoma, undoubtedly occur primarily in the dura mater, but in 



270 THE SPINAL CORD AND ITS MEMBRANES. 

many of the instances on record, it is manifest that the disease extended 
from the bones to the theca vertebralis. The same is true with regard 
to tubercular deposits ; in both cases, however, the membrane is liable 
to become secondarily involved, by extension of these diseases either 
from within or without the canal. 

An instance of melanotic growth apparently proceeding from the 
dura mater of the cord, is to be found in the Keport of the Pathological 
Society for 1847. Dr. Williams discovered it in a patient, aged forty- 
six, who, three years previously, had suffered from hemiplegia of the 
right side, following the extirpation of the right eye, for fungus. The 
patient recovered from this, and in the summer preceding his death was 
attacked with epilepsy : weakness and numbness of the lower extremi- 
ties, and inferior portion of the trunk, soon proceeding to complete 
paraplegia, supervened. The brain arid its membranes were found 
healthy; within the spinal canal, closely adherent to the theca extern- 
ally, there existed an irregular encephaloid mass, mottled with dark 
spots, extending from the third to the sixth dorsal vertebra, the bodies 
of which were carious and infiltrated with cancerous matter ; the por- 
tion of the cord beneath the tumor was flattened, soft, and wasted. In 
connection with this subject, we may also be allowed to mention the very 
rare occurrence of an accumulation of fat, a genuine fatty tumor, within 
the spinal column, in contact with, the dura mater; an instance of this 
kind was brought before the Pathological Society, in 1852, by Mr. 
Obre', in which death was produced in an otherwise healthy child by the 

Fig. 128. 




Part of the dorsal portion of the spinal cord of a young man who died paraplegic. A thick layer of lymph 
and tuberculous matter was found surrounding the dura mater, and slightly compressing the cord. It was 
manifestly an extension of disease from the adjacent vertebras and intervertebral cartilages. The cord and 
the dura mater appear healthy in texture. From St. Bartholomew's Museum, Series vii. No. 10. 

mere mechanical pressure exerted by a deposit of this kind. The lipo- 
matous growth was two and a half inches in length, the breadth of the 
canal, and about half an inch in thickness, composed of the ordinary 
spherical fat-cells: it did not differ from fat usually met with in other 
situations, excepting that the cells seemed to contain fat in a more solid 
and granular state. It lay between the theca and the bodies of the last 
cervical and first dorsal vertebrse. 



CHAPTER XII. 

THE ARACHNOID AND PIA MATER OF THE SPINAL CORD. 

Although the anatomical connection between these membranes is 
somewhat different from that obtaining between the cerebral meninges, 
it does not appear that their relation in disease differs materially from 
what we have found to prevail in that locality ; we shall, therefore, con- 
sider them together. 

The absence of valves in the spinal veins, and their peculiar distribu- 
tion, cause the circulation of the spinal cord to be very sluggish, and, 
therefore, prone to congestion and stagnation; to this, Ollivier attributes 
the great number of dilatations which we find in the different points of 
its extent, in individuals advanced in years. He adds, that he has 
generally remarked that the quantity of serum in the vertebral canal 
was so much the greater, according as there was a greater congestion in 
the veins of the spine, and of the membranous coverings of the cord; 
thus, the slowness and difficulty of the course of the venous blood may 
be here the causes of a dropsy, which is independent of inflammation of 
the spinal membranes. These effusions of serum will, according to the 
exciting causes, be of a chronic or acute character; in infancy, irritation 
frequently gives rise to a more rapid accumulation of fluid, while in old 
age a slow effusion is frequently met with, which Rokitansky attributes, 
in part, at least, to a secondary congestion, arising from atrophy of the 
medulla and the roots of the nerves. The fluid exhaled under such 
circumstances will follow the law of gravitation, and accumulate at the 
lower end of the spinal cord, and thus assist in exciting and perpetuating 
paraplegic symptoms of which we may be unable to detect a sufficiently 
satisfactory reason after death. The occurrence of sanguineous apoplexy 
of the meninges, in any form, is very rarely met with; Dr. Abercrombie 
gives a single instance, which occurred under his own observation, in a 
child, aged seven, in whom, after an illness of three days, death ensued 
after violent convulsions. A long and very firm coagulum of blood was 
found, external to the cord, extending the whole length of the cervical 
portion. An interesting case of hemorrhage under the pia mater, but 
external to the cord, is also quoted, from Dr. Stroud's notes, by Dr. 
Bright (p. 340). Numerous instances of spinal apoplexy occurring in 
children are given by Dr. Mauthner, but as no post-mortem appearances 
are recorded, the inferences are solely derived from the symptoms, which 
do not enable us to state positively the exact nature of the effusion. 
We possess more satisfactory and copious evidence regarding the in- 
flammatory affections of the spinal meninges, and it appears that it is a 



272 THE ARACHNOID AND PIA MATER OF THE SPINAL CORD. 

very frequent cause of death in new-born infants ; thus, Billard found, 
that in thirty cases of convulsions, there was meningitis of the cord in 
twenty, only six of which presented inflammation of the cerebral me- 
ninges. It is much less frequent in the adult, and is here almost invari- 
ably associated with, or consequent upon, cerebral inflammation. As 
a result of an acute inflammation of the membranes, we find lymph, or 
pus exuded, to a greater or less extent. Either may invest the entire 
surface of the cord, or it may be limited, as in a case that fell under 
our own observation, in a child of four years of age, to a space of an 
inch and a half in length. But we must be careful in at once concluding 
that we have to deal with a case of spinal meningitis, because we find 
the theca vertebralis lined with pus, for it may find its way from without 
into the cavity ; thus, in a case of psoas abscess, given by Dr. Bright, 
the sudden supervention of fatal symptoms was manifestly due to this 
cause ; a probe could be easily passed from the intervertebral foramina 
into the adjoining abscess. In the chronic form of spinal meningitis, 
the traces of the disease consist in greater or less opacity and thickening 
of the arachnoid, which frequently is found closely adherent to the spinal 
cord, and corrugated. 

The symptoms of spinal arachnitis are met in trismus neonatorum, in 
the shape of congestion of the spinal arachnoid, with an effusion of blood 
or serum into its cavity; and Dr West 1 also states that, in the three 
cases which he examined, he found effusion of fluid or coagulated blood 
in the cellular tissues surrounding the theca of the cord. This is not 
necessarily at variance with the statements of Dr Scholler 2 and Dr. 
Colles, 3 who attribute trismus to inflammation of the umbilical arteries, 
as this may, and is, found to coexist with the former. Symptoms of 
inflammation of the spinal membranes have also been met with in tetanus; 
but in by far the greater number of cases examined after death, no uni- 
form or adequate cause, to which the symptoms were referable, could 
be discovered. The importance of the predisposing causes is, probably, 
as great in tetanus as it is shown to be in trismus ; atmospheric states 
have a manifest influence in this respect, and an irritation set up in any 
part of the body, and propagated to the nervous centres, under such 
circumstances, induces the disease. The same absence of uniform pa- 
thological data exists in another disease, which we cannot but refer to 
the nervous centres, hydrophobia ; congestion of the cerebro-spinal mem- 
branes and nerve-matter, and some occasional effusion, is all that is 
generally met with in the shape of post-mortem effects; we need not add 
that these appearances cannot be considered as characteristic of the 
disease in question. Mr. Youatt, whose extensive experience of hydro- 
phobia in the brute creation, justifies our referring to him as an authority, 
states that the appearance of inflammation of rabies is of a peculiar 
character in the stomach, but that no conclusion can be drawn from the 
state of other organs. In discussing the changes occurring in the spinal 
cord itself, we shall have occasion once more to recur to the subject of 
tetanus. 

1 The Diseases of Infancy and Childhood, p. 125. 

2 Neue Zeitschrift fur Geburtskunde vonBusch, D'Outrepontund Ritgen, vol. v. p. 477. 

3 Dublin Hospital Reports, p. 285. 



THE ARACHNOID AND PIA MATER OF THE SPINAL CORD. 273 

In cases of long standing paralysis and paraplegia, we find evidence 
of chronic meningitis of the cord in the corrugation, opacity, and close 
adhesions of the membranes to one another, and to the cord. A good 
illustration of this is afforded by a case given in Dr. Bright's Reports 
(page 380) ; here, the dura mater of the cord was unusually firm and 
thick, and, as far as the middle of the back, closely adherent to the 
pia mater, from which, in most parts, it could not be detached without 
lacerating the cord. On attentive examination, it was found that the 
apparent thickening of the dura mater depended chiefly on a layer of 
membrane, of almost cartilaginous thickness, beneath it ; and was, pro- 
bably, rather the diseased arachnoid, or an adventitious deposit, than 
the dura mater itself. These appearances may be associated with fur- 
ther lesion of the cord, or with adventitious growths of the vertebral 
column or arachnoid. The only growths of this kind that are of fre- 
quent occurrence, are formations of bone on the visceral side of the 
latter membrane. In this respect, we perceive a characteristic distinc- 
tion between the head and the spinal column ; for while, in the former, 
ossific deposits are common in the dura mater, and are scarcely ever 
met with in the other membranes, in the spinal column they are found 
to prevail in the arachnoid, and not to affect the dura mater. A re- 
markable instance is recorded by Herbert Mayo, in his Outlines of 
Human Pathology, of osseous concretions surrounding the posterior 
roots of the nerves, and proceeding to the lower extremity. This, un- 
doubtedly, belonged to the class of pathological products under con- 
sideration ; and the case has a special interest, from its bearing upon an 
important law of nervous conduction. The pains suffered by the patient 
were so limited to the lower extremity, and were so excruciating, that 
the surgeon performed amputation of the limb, though with what results 
need scarcely be stated. 

Cartilage also forms, though less frequently, on the arachnoid. A 
good instance is recorded in the Reports of the Pathological Society of 
London, by Dr. Quain, 1 who describes the laminae as composed of a 
transparent matrix, in which were deposited small cells, containing 
nucleoli, and numerous small amorphous granules. 

It does not appear that there is a liability on the part of the spinal 
pia mater to tubercular deposit, as we find to prevail in the cerebrum. 
Rokitansky remarks on the subject, that he has never had occasion to 
suspect the exudation formed on the pia mater to be of a tuberculous 
nature, and that this observation accords with the fact that spontaneous 
spinal meningitis so commonly coexists with that form of cerebral menin- 
gitis which produces similar exudations. An acute tuberculosis, he adds, 
he has never observed in it. 

1 Reports, &c. 1849, p. 25. 



18 



CHAPTER XIII. 

THE SPINAL CORD. 



The forms of disease and their effects, which present themselves in 
the spinal cord, closely resemble those we meet with in the brain. The 
spinal cord does not appear to be so often attacked as the encephalon, 
and as we have already pointed out, it is the part which is generally 
left unexamined, unless attention is forcibly directed to it by the pre- 
vious symptoms of the patient; for both reasons the records of its 
pathological states are much more scanty than those regarding the 
brain, and future inquirers have yet a large field to explore. The 
evanescent character of congestion rarely allows of its being demon- 
strated after death ; though it is impossible to believe that there should 
not be accumulation of blood in the cord, in those instances in which 
the symptoms demonstrate intense irritation of the 
Fig. 129. part, as in tetanus ; a case of hydrophobia is re- 

corded by Dr. Bright, in which a blush of redness 
was perceived in the cineritious part of the spinal 
cord opposite the second and third cervical ver- 
tebrae. An ansemic condition of the cord is as dif- 
ficult to demonstrate at its converse, though here 
too the practitioner will not fail to suggest instances 
in which its existence may be fairly assumed during 
life. Both states manifest themselves in the se- 
condary effects of hypertrophy and atrophy. 
These may be general or local ; the former affection 
belonging chiefly to early life, and the latter, like 
the corresponding condition in the brain, to old 
age. Atrophy of the spinal cord is one of the pa- 
thological conditions met with in the disease known 
as tabes dorsalis ; in this case it is more of a local 
character, involving only the lumbar segment of 
the cord and the nerves passing off from that part. 
The separate divisions of the cauda equina are often 
found entirely deprived of their medulla, and 
nothing but the neurilemma may remain. A local 
atrophy, as the effect of the compression exerted 
by morbid growths or displacement of the vertebrae 
is frequently met with, and in these cases it is of peculiar physiological 
interest to observe the limitation of the symptoms of nervous affection 
according to the extent to which the pathological condition involves the 



Part of a spinal cord 
from a case of paraplegia, 
with angular curvature of 
the spine, in a lad aged 
eighteen. Opposite the 
contracted part of the cord, 
a short process of bone 
projected from the angle 
of the curvature into the 
spinal canal. — From St. 
Bartholomew's Museum, 
Series vii. No. 7. 



THE SPINAL CORD. 275 

medulla. Numerous instances are recorded by writers on the subject ; 
among whom we would particularly refer to Ollivier, Longet, and Rom- 
berg. Both in atrophy and hypertrophy of the spinal cord, the tissue 
is commonly indurated and firmer than in the normal state. 

Cases of the termination of myelitis, or inflammation of the cord, in 
the first stage, like those of encephalitis, are scarcely ever met with ; it 
becomes the question whether, owing to the peculiarity of the nervous 
structures, the first onset of inflammatory action is not at once accom- 
panied by those changes, which in other tissues are looked upon as the 
secondary products of inflammation. An essential difference appears 
to prevail between the brain and spinal cord with regard to one of the 
results of congestion, hemorrhagic effusion. The frequent occurrence 
of apoplexy of the encephalon is familiar to all ; its idiopathic occur- 
rence in the spinal cord is extremely rare, and when brought on by 
external lesion, such as fracture of the vertebrae, or penetrating wounds, 
it is commonly associated with hemorrhage on the surface. The cases 
collected by Dr. Abercrombie all appear to be instances of effusion be- 
tween the meninges and the cord itself. The rarity of the occurrence 
may justify our extracting the following observation from the Report of 
the Pathological Society for 1849, p. 28 : — 

u A gentleman, aged 44, who, with the exception of occasional at- 
tacks of gout, had previously enjoyed good health, was suddenly seized 
one evening with violent spasm in the stomach, and found that he had 
lost all sensation and power of motion in the lower half of the body. 
Mr. Curling found him an hour later with complete paraplegia below 
the third ribs, and strong priapism ; no excito-motory movements were 
producible, and the mind was perfectly clear. The priapism subsided 
in about twenty-four hours ; there was no extension of paralysis, ex- 
cept a feeling of numbness of the hands, and at last imperfect power of 
Using them. During the first eighteen hours after the attack, scarcely 
any urine was secreted, and it subsequently became scanty in amount. 
The patient died four days after the seizure. The spine was examined 
seventeen hours after death. The muscles of the back were much 
loaded with blood — no fluid escaped on opening the theca vertebralis, 
the head being in a depending position. The vessels on the surface of 
the cord were a good deal congested. An incision was made above the 
front of the medulla, commencing at the part corresponding to the 
third cervical vertebras, and terminating at the last dorsal; two small 
clots of blood, amounting together to about a drachm, were found in 
the interior of the medulla, occupying about an inch and a half in ex- 
tent, and situated between the origins of the second and third pairs of 
dorsal nerves. The substance of the cord around the clots was some- 
what soft ; the medulla was more or less infiltrated and stained with 
blood from the site of the clots upwards as high as the third cervical 
vertebrae, and downwards as low as the last dorsal." 

No microscopic examination of the parts appears to have been made ; 
future observation must determine whether atheromatous, or other dege- 
neration of the arteries, or previous derangement in the nutrition of the 
adjoining tissues, is the causa proxima of spinal, as it so frequently is of 
cerebral hemorrhage. The above case does not tally with the statement 



276 THE SPINAL COED. 

of Rokitansky, that, when hemorrhage occurs in the spinal cord, it is in 
the cervical portion. 

The product of inflammatory action most commonly discovered in the 
spinal cord is ramollissement, a condition which, however, like its ana- 
logue in the brain, is equally attributable to other pathological states, 
each of which may be recognized by the naked eye, and the aid of the 
microscope. The degree of softening varies from a slight diminution of 
consistency, as compared with surrounding parts, to a state of pulpy 
diffluence ; the extent of cord affected differs equally. In paralysis, we 
very frequently meet with no other trace of disease but a trifling soften- 
ing in the lumbar, dorsal, or cervical regions, manifestly the result of a 
slow inflammatory process. The microscopic products of inflammation, 
the inflammation corpuscles and granules, spoken of in considering the 
similar conditions of the brain, are also found in the present instance ; 
and where any doubt prevails as to the nature of the softening, these 
microscopic appearances will aid our judgment. MM. Rilliet and Bar- 
thez have invariably found that, in children, the softening of the white 
matter of the cord coexisted with inflammation of the membranes, and 
that the extent of the former was in the exact ratio of the amount of 
the latter. 

The softening affects the gray matter, and especially that belonging 
to the lumbar and brachial swellings more than any other part ; and a 
case is given by Ollivier, in which the entire gray substance of the cord 
was converted into a pulpy mass, leaving the white matter in a compara- 
tively healthy state. We meet with diffused suppuration in the cord as 
in the brain ; circumscribed abscess is also, though very rarely, found 
within the medullary matter. Dr. Abercrombie 1 gives a case of this 
which occurred in a woman aged fifty-six, who was affected with sudden 
loss of power of the limbs of the left side, followed by death in a week. 
The brain was sound, but in the centre of the right column of the spinal 
cord, in the middle of the cervical portion, there was a cavity three 
inches long, and two or three lines in diameter ; it was full of a soft 
matter, like pus, which became more consistent towards the parietes of 
the cavity. 

It appears that the softening invariably proceeds from the gray to 
the white matter in myelitis. It is probable that where the process is 
a result of exhaustion, malnutrition, or degeneration, the reverse will 
be found to obtain ; as the former would be favored by the presence of 
a large number of bloodvessels, the latter would spread more in a part 
not copiously supplied with them. The tint of the gray matter is deep- 
ened, and a rose-blush pervades the white matter in the red form, while 
this hue is replaced by a more or less yellow tinge when the suppurative 
stage has set in. A form of white softening occurs in the spinal cord 
which is analogous to the white softening met with in the brain, as a 
result of the effusion of serum or oedema, which is in no way connected 
with inflammation. 

Another product of myelitis is induration of the cord ; this is found 
coexistent with ramollissement, or by itself. It is more frequently 

1 Diseases of the Brain, &c, 1845, p. 355. 



THE SPINAL CORD. 277 

brought on by chronic or cachectic inflammation than softening, and it 
is not unfrequently complicated with hypertrophy of the affected part. 
When the induration is very considerable, the nerve-tissue resembles, as 
Ollivier observes, in consistency, density, and appearance, boiled white 
of egg ; it is a condition that Esquirol has repeatedly met with in epi- 
leptic subjects. Gluge, 1 in adverting to the extreme difficulty of a minute 
analysis of all the elements of disease occurring in nerve-matter, alludes 
to the coagulability of the contents of the tubules as a point of great 
importance, though he admits the obstacles that oppose themselves to 
a determination of such relations in disease. He is inclined to think 
that the coagulation takes place in certain diseases, such as tetanus, 
during life. That a change in the contents of the nerve-tubules must 
materially affect their conducting power, is too manifest to require 
enlarging upon theoretically ; still, the proof has, as yet, evaded our 
means of demonstration. 

Softening of the spinal cord occurs, as in the brain, as a sequel of 
morbid growths, such as carcinoma, or tubercle. Neither of them is, 
however, frequently met with, though they are oftener seen in the cord 
itself than its membranes. Ollivier, whose work contains the largest 
collection of cases of this kind on record, denies the occurrence of me- 
lanosis affecting the cord, nor have we been able to discover any other 
instance but the one already alluded to, in which the melanotic tumor 
was attached to the dura mater. 

■ Acephalocysts are also met with in the spinal cord. Rokitansky 
states that he has repeatedly met with the cysticercus in the cervical 
portion of the spinal marrow; but his experience agrees with that of 
Ollivier, that they do not occur in the substance of the medulla. They 
in most instances are situated externally to the dura mater. In this 
case, it is manifest that they had been first developed outside the column, 
and had forced their way in through the intervertebral foramina; they 
have, however, also been found within and underneath the arachnoid. 
It is a curious fact, for which we can offer no explanation, that the cases 
of acephalocyst occurring in the spinal column, have all been females. 

In concluding the subject of the pathological anatomy of the spinal 
cord and its membranes, we must again express our regret that our 
knowledge of the morbid changes occurring in it are in no way com- 
mensurate with the importance and dignity of the organ. With refer- 
ence to no other part of the body are we so often at a loss to explain 
the connection which exists between the symptoms of disease, and the 
actual pathological condition of the organ. The hyperesthesia of the 
spinal cord (which is manifested in so marked a manner in tetanus, hy- 
drophobia, hysteria, and poisoning by strychnine) is a palpable derange- 
ment of its functions; and yet the anatomist can discover no satisfactory 
reason to satisfy his desire for establishing the etiological relation. A 
comparison suggests itself between these cases of diseased action which 
appear as yet to be out of the reach of science, and those calamitous 
accidents on our railways which generally seem to be due rather to some 

1 Atlas der Pathologischen Anatomie, Lief. xx. p. 12. 



278 THE SPINAL CORD. 

Deus ex rnachind, than to those physical laws which are generally sup- 
posed to rule mechanical appliances. Had we desired to enter into 
theoretical discussion, either regarding the brain or the spinal cord, 
much more might have been said on the subject; and we have carefully 
abstained entering into the debated ground of hypothesis, as, for in- 
stance, with regard to the participation of these organs in fever, as we 
should thus have outstepped the limits which the practical character of 
this work seems to impose upon us. 



CHAPTER XIV. 

THE NERVES. 

It very rarely happens that individuals die of an affection residing 
solely in the nerves; consequently, we are left to surmise their morbid 
appearances in those diseases in which they are manifestly affected, from 
analogy. At the same time, we must never forget that the nerves are 
not central organs, but that they are the telegraphic wires destined to 
convey intelligence to and from the central organs. When, therefore, we 
have to deal with a nervous symptom, we must first inquire whether it 
be due to a centric or to a peripheral cause; or, in other words, whether 
the nerve is propagating a morbid impression from the brain, the spinal 
marrow, or the sympathetic ganglia which may simulate peripheral dis- 
ease, or whether it is giving evidence of local disease by producing 
in the brain the consciousness of that affection. In the majority of 
instances of irregular or painful action of the nerve, we should be as 
much in error in seeking for the cause of the derangement in the nerve 
itself, as if, when our galvanic battery does not act, owing to the trough 
containing no acid, we sought to remedy the defect by changing the 
conducting wires. 

The nerves have repeatedly been made the subject of inquiry in dis- 
eases, in which either local symptoms predominate, or in which, from 
the known physiological action of the nerves, controlling the parts 
affected, the morbid phenomena could fairly be sought in an individual 
nerve; thus, the sciatic has been subjected to examination in individuals 
who had been affected with sciatica, and the vagi have been explored as 
the hypothetical excitants of hooping-cough. Pathologists have, in 
neither case, succeeded in demonstrating a relation between the malady 
and an uniform alteration in the respective nerves. A case has long 
been transcribed, and has thus acquired traditional importance, by which 
Cotugno, the first who wrote on sciatica, is made to affirm a lesion, 
oedema of the nerve, as the causa proxima of that malady; but although 
he records a case of the kind, he himself would certainly not have ap- 
proved of the interpretation which has been given to it, since he dis- 
tinctly states that he attributes no importance whatever to the circum- 
stance. With regard to hooping-cough, we find instances recorded of 
the vagus having been reddened and swollen, indicating inflammatory 
action, but the large majority of cases in which the point has been 
attended to have presented no such change. Thus, Dr. Albers examined 
the vagi, in forty-seven children who had died of hooping-cough, and 
found them perfectly normal in forty-three ; Dr. West, who has also 



280 



THE NERVES. 



Fig. 130. 




paid especial attention to the subject, has, only in one case out of eigh- 
teen, met with any change in the nerves ; in this case they were de- 
cidedly redder than usual. We are inclined to conclude, with the latter 
author, that an appearance so frequently absent 
cannot be one of much moment, and that, like 
Cotugno's famous case, to which we have just 
referred, it may be set down to a cadaveric 
change. In our examinations of nerves, sup- 
posed to be diseased, we must be careful to dis- 
tinguish between the neurilemma and its altera- 
tion, and the nerve-tubes ; thus, in the stump 
of an amputated limb, we commonly find the 
nerve terminating in a button; this is owing to 
the effusion of plastic matter, which serves as 
a protection to the divided nerve, and not to an 
hypertrophy of its tubules. 

The morbid condition most commonly seen in 
the nerves throughout the body is atrophy; this, 
however, can rarely be said to be a primary 
affection ; it is brought on by the influence of 
pressure, acting immediately upon the nerve, 
and causing gradual, and even entire absorption 
at the point upon which the pressure acts; this 
we find occurring in the case of aneurism, or 
enlarged glands, lying in the vicinity of nerves. 
Atrophy of the nerve results from the part to 
which it is supplied ceasing to perform the func- 
tions for which it receives the nerve ; thus, 
atrophy of the optic nerve may follow destruc- 
tion of the eye, by mechanical injury; or the 
nerve of an extremity wastes, when the muscles 
of the part are condemned to inactivity. A case is related by Swan, 1 
in which, however, other nerves, the vagi, appear to have been idiopa- 
thically affected with atrophy. An individual had, for eighteen months, 
been unable to satisfy his appetite ; the food was vomited four hours 
after being taken, without showing any signs of digestion ; respiration 
became laborious and sibilant; emaciation and death ensued. At the 
section, the lungs were found normal, but the vagi, from the middle of 
the neck, were atrophied, and their terminations in the oesophagus red 
and thickened. The left was found smaller than the right. Mr. Swan 
adds that, in two consumptive patients, he found the vagi smaller than 
usual. In cases of atrophy and degeneration of the spinal cord, the 
nerves passing from the diseased portion are, necessarily, in an atrophic 
condition : thus, in an instance given by Cruveilhier, 2 in which the dis- 
organization of the cord was limited to the posterior strands, extend- 
ing from the lower end to the cerebellum, the posterior nerves were en- 
tirely atrophied and converted into transparent threads, which contrasted 



Portion of a cerebrum with the 
optic nerves and remains of the 
left eye. The cornea is opaque, 
and the coats of the eye are col- 
lapsed. The left optic nerve is 
considerably diminished in size be- 
tween the diseased eye and the op- 
tic commissure. Behind the com- 
missure, the nerve on the right 
side is rather smaller than that on 
the left, but the thalami appear to 
be of equal size. From St. Bar- 
tholomew's Museum, Series viii. 
No. 5. 



1 Treatise on Injuries and Diseases of the Nerves. London, 1834, p. 174. 
3 Anat. Pathol. Livr., xxxii. p. 19. 



THE NERVES. 281 

strongly with the normal appearance of the anterior nerves. It would 
appear that an idiopathic atrophy is met with in the nerves of sense, 
at least the acoustic and optic nerves have been found atrophied, in cases 
of blindness and deafness, where none of the ulterior causes alluded to 
were traceable. Rokitansky states that, under certain circumstances, 
nerves which are extremely atrophied acquire a grayish, translucent ap- 
pearance, especially within the skull, and that the coloring is produced 
by the presence of a blastema filled with numerous nuclei, which, at 
first gelatinous, and afterwards tough and elastic, takes the place of the 
nerve-tubes as they disappear ; it becomes more distinctly visible, as the 
original neurilemma of the affected nerve diminishes. He adds, that 
the vessels of a nerve in this condition are often palpably dilated. 

Whether true hypertrophy of the nerve ever occurs is a matter that 
scarcely bears direct proof; a priori, we may assume that a nerve en- 
larges in proportion to the functional activity of the organ to which it 
belongs •, an hypertrophied muscle is only enabled to manifest its power 
if its nerve be also hypertrophied. In such a case, there is probably 
an increase in the nerve-tissue itself. Enlargements of a different kind 
are found in nerves which are traceable to the neurilemma, or to a fibrin- 
ous deposit within the latter, as in the case of tumors of the nerves, 
following injury or division. After our preliminary remarks on the 
pathology of the nerves, we need say little about the appearance pre- 
sented in congestive or inflammatory states; it is questionable whether 
they are ever subject to any idiopathic affection of the kind, and when 
the surrounding parts are involved, these invariably attract much more 
attention than the nerve itself. Moreover, the statements on record, 
though but scanty, do not agree; thus, to return again to the vagus, 
which has always been the pet nerve of pathologists, probably owing to 
its size and superficial site, we find that Kilian has observed it to be in- 
flamed fifteen times, in pertussis, while Breschet has only met with the 
occurrence twice, a relation that is the more surprising when we recol- 
lect that the sphere of observation of the former is a small German 
provincial town, and that of the latter, the capital of France. Auten- 
rieth, also, states generally that he has found the vagi inflamed, in per- 
sons who have died of spasmodic cough. The neurilemmatous sheath 
is the part mainly affected in inflammation ; it presents an increase of 
redness, of more or less intensity; the infusion of serum induces a ful- 
ness and swelling of the nerve, and the nerve-tubules themselves become 
separated, and, as it were, unravelled. The exudation of fibro-plastic 
matter follows, and, by compression of the fasciculi, may cause their 
obliteration; or, if resolution ensues, the nerve may be restored to its 
primitive condition, or again the part may accommodate itself to the 
change, and the nerve remain permanently enlarged and somewhat no- 
dose. After partial or total division of a nerve, these changes are liable 
to occur, and in an irritable constitution the deposit of lymph continues 
to act as a source of irritation, and induces intense pain. The occur- 
rence of suppuration within the sheath necessarily gives the nerve a 
yellow color, and causes the tubules to be broken up. In all inflamma- 
tory affections of the nerves, the cellular tissue surrounding them will 
likewise be found inflamed. Two cases of inflammation of the nerve 



282 



NEUROMA. 



are given by Mr. Curling, 1 in his treatise on tetanus, in which healthy 
spots were found, between which the nerve-tissue appeared inflamed. 
M. le Pelletier 2 has also published several cases, in which the inflam- 
mation appeared propagated along the injured nerve, to the spinal cord, 
in the same disease. The most complete investigation, however, has 
been made by Froriep ; 3 in seven cases of tetanus, in which injury of a 
nerve had preceded, he has discovered a uniform lesion, resembling that 
indicated by Mr. Curling, and consisting in a tumefaction and redden- 
ing of isolated tracts, extending from the wound to the spinal cord; he 
has not found it in other cases, in which no tetanic symptoms prevailed. 
We have already had occasion to observe that there is no uniformity in the 
post-mortem appearances in the central organs of the nervous system in 
tetanus; it is satisfactory, at least, to know of one symptom which 
appears to be established, and which, at the same time, may afford an 
indication with regard to the necessity of local treatment, in preventing 
the propagation of the irritation from the peripheral parts to the central 
organs. 

NEUROMA. 

Of the morbid growths found in nerves, the so-called neuroma is the 
most common. In the idiopathic form, it is a growth which occurs 



Fig. 131. 



Fig. 132. 





A stump of the upper extremity, showing the 
bulbous termination of the median, internal 
cutaneous, musculo-spiral, and musculo-cuta- 
neous nerves; the circumflex passes behind 
the teres major and its termination is not seen. 
— From St. George's Museum, a. 35. 



Neuromata of stump, after amputation of the 
arm. A large neuromatous mass at a ; opposite b, 
the tumors are more defined. 



within the sheath of the nerve, but does not in any way fuse with the 
nerve-tubules; it forms on the neurilemma, and, by gradual expansion, 



1 A Treatise on Tetanus, 1836, p. 72. 

2 Revue Medicale, 1827, vol. iv. p. 183. 



Neue Notizen aus dem Gebiete der Natur und Heilkunde, 1837, vol. i. No. 1. 



NEUKOMA. 



283 



separates the nerve-fibrils from one another, which, with care, may 
always be traced from the upper to the distal part of the trunk of the 
nerve. We have already alluded to one kind of neuromatous forma- 
tion — the button found at the termination of the divided nerve in 



Fig. 133. 



Fig. 134. 





Section of a neuroma; three nervous trunks 
terminating in it. The fibrous arrangement 
shown, as observed by the naked eye.— Smith. 



Fibrous structure of neuroma; from the ease published 
by Dr. Smith, of Dublin. After immersion in spirit> 
which has caused corrugation of the granules and cor- 
puscles. — From a drawing by Dr. Bennett. 



stumps. In this case, the nerve necessarily ends in the tumor, the 
fibrous tissue of which the swelling is composed blending with nerve- 
tissue, which it is destined to protect from external injury. If this view 
is correct, and we are supported in it by Mr. Langstaff, the swelling can 
scarcely be looked upon as morbid, but rather as the evidence of the 
curative efforts of nature. The idiopathic neuroma occurs without any 
known cause, in the shape of a round or oval tumor, varying in size 
from a grain of wheat to that of a pumpkin, and in number from one to 
several hundred. It must be classed among the non-inflammatory 
growths. The tumor is generally solid throughout, though occasionally 
it contains a cavity. It has a tendency to increase in size, and the 
nerve-fibres are proportionately distended and separated. They may 
generally be easily detached from the nerve. On section, the texture is 
found to be dense and homogeneous, closely resembling that of a fibrous 
tumor in other parts of the body ; presenting under the microscope a 
fibro-cellular structure, the fibres being arranged in bands or loops, in 
which oval or elongated nuclei become apparent on the addition of 
acetic acid. Sometimes the tumor is of an atheromatous character. 
Dr. Smith 1 has published two cases of neuroma which are instances of 
the occasional extravagant production of these growths; in them, almost 
every spinal nerve was closely studded with neuromata, which did not, 

1 A Treatise on the Pathology, Diagnosis, and Treatment of Neuroma. By A. W. 
Smith, M. D., &c, Dublin, 1849. 



284 



NEUROMA. 



however, give rise to much uneasiness ; in fact, it appears, as also 
noticed by the same author, that they are rarely productive of much 
pain when in great numbers ; whereas the solitary neuroma, which is 



Fie. 135. 



Fig 136. 



Fig. 137. 





Fig. 135 — A posterior tibial nerve, in which there is a circumscribed oval tumor, composed of a soft grumous 
substance. The component fasciculi of the nerve are separated and spread out around the tumor, the pero- 
neal nerve is adherent to the surface of the neurilemma, extended over the tumor. — From St. Bartholomew's 
Museum, Series viii. No. 1. 

Fig. 137. — A median nerve, in which is imbedded a small tumor, over which the filaments are spread out. 
St. Bartholomew's Museum, Series viii. No. 13. ' 

generally known by the name of painful subcutaneous tubercle, is cha- 
racterized by agonizing pain. Other adventitious growths do not 
appear to affect the nerves of the spinal system primarily; they are 
involved in cancerous degeneration, by the extension of the disease from 
adjoining tissues ; and in the nerves of the senses we also meet with the 
primary formation of cancer. In the retina, medullary carcinoma is 
not unfrequently found unassociated with cancerous growths in . any 
other part of the system. 



CHAPTER XV. 

THE SYMPATHETIC SYSTEM. 

A few cases are on record in which the ganglia of the sympathetic 
system were found more or less deranged and altered in structure. It 
is probable that a series of nervous centres, like that presented in the 
sympathetic, are much more frequently diseased than we have it as yet 
in our power to demonstrate. We can scarcely conceive that the so- 
called functional derangement of the heart, for instance, can continue 
as it does, for a series of years, and the nerves controlling its action not 
be or become organically altered ; in the same way, long-standing de- 
rangement in the nutritive and secretive functions of the abdominal vis- 
cera may be assumed to give rise to material changes in the cceliac and 
semilunar ganglia, as the numerous diseases of the generative organs 
can scarcely exist without a similar influence being exerted upon the 
spermatic plexus. The anatomical disposition, as well as the physio- 
logical manifestations of the range of action of the sympathetic, justify 
our belief in its great and powerful agency in disease ; the actual 
demonstration of the fact is, however, yet reserved for future inquirers. 
Bichat 1 repeatedly examined the nerves of the viscera in different dis- 
eases without discovering any lesions. With the exception of a single 
case, he has found the semilunar ganglion intact in cancers of the 
stomach. In a case of periodic mania, he found this ganglion of the 
size of a small nut, with a cartilaginous centre. 

Several authors have reported cases in which one or more of the 
ganglia of the sympathetic were found congested and inflamed in tetanus. 
Swan 2 has noted this condition in each of the three cases in which he 
made a post-mortem examination of tetanic individuals ; in the first, he 
found a very distinct inflammation of the semilunar ganglia; in the 
second, it is described as a remarkable redness, which appeared, through- 
out, to be produced by a very minute injection of the cellular tissue, 
interspersed between the small grains of which the ganglia are composed; 
and in the third, he states that there was an enlargement, and a greatly 
increased vascularity of all the ganglia of the sympathetic nerves, in 
the chest, and also of the semilunar ganglia ; in several of those in the 
abdomen, the same appearance existed, only in a less degree ; but in 
some there was neither the least redness nor enlargement. 

That this, however, is not a uniform lesion, and not noted because 
overlooked, or not attended to, is proved by a case of traumatic tetanus, 
given in Dr. Bright's Reports. (Case cclxxvi.) A boy had been injured 

> Anatomie Generate, i. 225. 2 On Tetanus, p. 325. 



286 THE SYMPATHETIC SYSTEM. 

in the heel by a circular saw, and had suffered a fracture of the left 
humerus ; a week after the accident he was seized with tetanus, and 
died, forty hours from the first appearance of this affection. The post 
mortem is stated to have been conducted with the greatest care by Mr. 
Bransby Cooper and Mr. Key, twelve hours after death, and there were 
no diseased appearances discoverable; the brain was most minutely exa- 
mined, as was the spine, through its whole course ; the same attention 
was paid to the sympathetic, the nerves and the ganglia of which, 
throughout, appeared healthy and white. The nerves were turned down 
to the wound in the leg, and were also found healthy. We have given 
this case in detail, because it bears upon all the points already discussed, 
regarding the pathological anatomy of tetanus; and while it proves that 
none of the morbid appearances pointed out by various observers are 
essential, it also bears strong evidence to the non-inflammatory nature 
of the disorder. At the same time, it does not destroy the value of the 
testimony which we have found in favor of frequent physical alterations 
in the nervous centres, only it alters the interpretation which we might 
otherwise put upon them. In tetanus, the equilibrium of the forces, 
whose balance is necessary to the due performance of the functions of 
the nervous system, is destroyed, and it is quite compatible with our 
knowledge of pathology and of physiology, that this should occur, with- 
out any primary change in the circulating organs, while, on the other 
hand, we are equally justified in assuming that a state of congestion and 
inflammation may react upon the nervous system in such a manner as 
to entirely alter its normal relations. In the latter case, we should, under 
such circumstances, still be at liberty to view the morbid appearances, 
induced by the vascular system, either as the cause or the result of the 
changes in the balance or polarity of the nervous sphere. 

It appears that the sympathetic system may also, though very rarely, 
be the seat of neuroma. Dr. Smith gives an instance of it occurring in 
the cervical ganglia, and figures it ; it is, probably, the same case which 
is described by Cruveilhier, 1 as a case of fibrous transformation, and 
enormous development of the cervical glanglia, and the nerves of com- 
munication passing between them. One of the tumors was two and a 
half inches long by one in breadth. Both authors state that their sub- 
ject was accidentally discovered in the dissecting-room in Paris, and that 
no history of the case was obtainable. 

Dr. Smith, in alluding to this remarkable degeneration of the cervical 
ganglia, states that, according to Schiffner and Bischoff, this condition 
of the sympathetic frequently coincides with idiotcy and cretinism ; it is 
a point which requires further confirmation. 

4 Anat. Pathol. Livr. PI. iii. 



PATHOLOGICAL ANATOMY OF THE ORGANS 
OF CIRCULATION. 



CHAPTER XVI. 

GENERAL OBSERVATIONS. 

Until a very recent date, the pathology of the heart was one of the 
most obscure departments of medical science, and the ignorance of the 
profession on the subject was veiled by terms which implied hypothetical 
views of the derangements which appeared most certainly referable to 
this organ. The most prominent among these were angina and hydrops 
pericardii; the one supposed to represent the climax of functional dis- 
eases, the other of organic changes. What the discovery of the circu- 
lation, at the beginning of the seventeenth century, by our great country- 
man, Harvey, contributed, to illustrate the uses of the heart and the 
vessels, in a physiological point of view, may be said to have been 
equalled in pathology by the application of the physical method of re- 
search in disease and at the dissection-table, introduced into the science 
of medicine during the present century. So long as we did not possess 
definite means of tracing morbid action in the living, it was impossible 
to correctly appreciate the phenomena presented in the dead subject. 
And thus we find that the two studies, mutually assisting and elucidating 
one another, have gone hand in hand. Far as a modest estimate must 
as yet admit pathology to be, from that to which an augmented know- 
ledge of morbid processes may lead future inquirers, it is impossible to 
look back to the history of this branch of science without a feeling of 
congratulation; for, while every step in advance raises the intellectual 
standard of the profession, and diminishes the skepticism which even its 
most distinguished members are occasionally observed to express with 
regard to its actual capabilities, the mass of mankind are no less bene- 
fited both by the increased means of avoiding and preventing morbid 
influences, and of checking their progress when once they have fixed 
upon the system. But while we have succeeded in determining more 
uniformly and positively the locale of disease involving the central 
organ of the circulation, we have also discovered what may be called a 
type of the relation existing between the poisoned condition of the blood, 
to which we are justified in referring the great majority of pathological 



288 GENERAL OBSERVATIONS. 

processes, derangement of function, and disorganization of structure in 
a part of the economy. The doctrine of metastases, a favorite hobby 
of some of the older writers, has been materially modified by an ex- 
tended knowledge of this relation ; and at the same time an enlightened 
humoralism has simplified the theory of disease, and has tended to bring 
us nearer to the causa proxima of numerous processes which other- 
wise offer no analogy or rationale. The morbid anatomist must never 
forget that he has to deal, not with disease itself, but only with its pro- 
ducts; and while it is of extreme importance that he should not isolate 
a single morbid phenomenon found in the corpse, but take the entire 
complex of derangements that present themselves, before he ventures to 
analyze and draw his conclusions as to their origin and connection with 
one another, and with the symptoms produced during life, he must also 
remember that the very cessation of life must alter the conditions of 
disease, and that there will always remain much that bears upon its in- 
telligence, which neither scalpel, microscope, nor reagent, will be able 
to detect when the vital spirit has fled. A certain amount of hypothesis 
must, therefore, be had recourse to, to establish and satisfy the legiti- 
mate demands of science; but this theory must be based upon the entire 
range of our physical knowledge, and only proceed within those limits 
which are placed by the laws of rigid induction. It is by pursuing this 
system of research that the proclivity of the heart to be affected in rheu- 
matism has been established, that we have determined fatty degeneration 
of the heart to be a frequent consequence of depraved nutrition, or that 
the close relation between renal and cardiac disease has been ascertained. 
The post-mortem examination alone would probably have established 
these facts as little as clinical observation taken by itself; but the two 
combined and practised by the master-minds of our century have led to 
results which, indeed, form an epoch in the annals of medicine. It is 
our duty to deal mainly with the cadaveric phenomena, but it is impossi- 
ble to treat them intelligibly unless, as we have throughout sought to do, 
we keep in view the vital relations of the various organs in disease. 
After these brief preliminary remarks, we proceed, first, to consider the 
morbid anatomy of the fibro-serous investment of the heart, the peri- 
cardium. 



CHAPTER XVII. 

THE MORBID ANATOMY OF THE PERICARDIUM. 

The diseases affecting the pericardium partake of a double character, 
owing to the two constituents which enter into its tissue, the fibrous and 
the serous layer ; on the one hand they are allied to the affections of 
fascial and tendinous formations, on the other to those of pure serous 
membranes. The morbid process that commences in the one may be 
propagated to the other, and the effects of disease occurring in one may 
be manifested by the products peculiar to the other. We deem it the 
more important to insist upon this point, as it bears strongly up.on the 
difference between the various post-mortem appearances, and because it 
aids us in appreciating the pathological distinctions between pericardial 
and endocardial disease. These are particularly manifested in their 
relation to the erases ; while the morbid products found in the pericar- 
dium are generally evidence of active disease, the endocardium almost 
serves as an index for the amount of crasis prevailing in the system ; at 
least, no membranous structure so frequently presents alterations in those 
constitutions which we have elsewhere considered as characteristic of 
blood erases. 

The frequency of morbid alterations in the pericardium increases with 
age, a proclivity which is not marked in the same degree with regard to 
the internal lining of the heart, which is much more prone in childhood 
to take on diseased action, than we should be inclined to assume a priori. 
Congenital affections of the pericardium are very rare, and though cases 
of its entire absence are recorded by observers like Baillie and Breschet, 
the majority of instances that have been classed under this head, have 
been shown to be only apparent anomalies, owing to intimate adhesion 
between the two surfaces of the sac giving rise to the semblance of the 
defect. A case of undoubted absence of the pericardium, where the 
heart lay in the same serous sac with the left lung, has recently been 
observed by Dr. Baly, in a man aged thirty-two. 1 It appears that an 
hypertrophic condition of the pericardium may occasionally occur so 
early in life as to seem congenital; we allude to the so-called milk spots, 
which are yet considered by various authors as results of inflammation 
exclusively. This is the view of Mr. Paget, while Dr. Hodgkin is in- 
clined to look upon them as the product of attrition only, as they are 
almost universally found on the anterior surface of the heart, at the 
point most in contact with the anterior walls of the thorax. The dis- 
crepancy is probably reconciled by the observation that there are two 

1 Report of Pathol. Society, 1S51, p. 60. 

19 



290 PERICARDITIS. > 

kinds of white spots, as was well laid down by M. Bizot ;* the one, pro- 
bably, owing to an inflammatory, the other to a non-inflammatory con- 
dition of the pericardium. They are cream-colored opacities of the 
visceral layer, varying in size from that of a sixpence, to that of a five- 
shilling piece, and more ; which may at times be detached from the 
subjacent serous membrane, to which they are then connected by cellular 
adhesions. In other cases they are mere thickening of the pericardium 
itself, or rather of the subserous cellular tissue, and cannot in that case 
be detached from it. The former, to use the accurate description of 
M. Bizot, present at their commencement the form of small transparent 
elevations, aggregated together with circumscribed edges, and but slightly 
adherent to the serous membrane. They soon lose their transparency, 
becoming white and opaque, but still capable of being removed without 
injury to the subjacent serous membrane. They occupy every portion 
of the heart, but lie chiefly in the direction of the bloodvessels. The 
second variety have no circumscribed margin, they are peculiarly white, 
and their greatest thickness is in the centre from where they are bevelled 
off in all directions; these are essentially identical with the pericardium 
itself, and constitute a true hypertrophy of the membrane. It is import- 
ant to arrive at a definite conclusion with regard to their origin, since 
their great frequency influences our views in regard to the prevalence 
of inflammatory affections of the membrane, and assists in determining 
our choice of treatment. Dr. Latham includes them in his table on the 
relative frequency of pericarditis in rheumatism, and thus establishes a 
ratio different from what we should arrive at if they are proved to be of 
non-inflammatory origin. We are ourselves of opinion that they are to 
be viewed as resulting from two causes ; and that while they are in 
many instances the results of previous inflammation, they may also 
represent a simple hypertrophic condition resembling the horny thick- 
enings of the cutis. The great frequency of the occurrence of milk 
spots 2 in Bright's disease of the kidney, tends to prove their connection 
with a blood crasis, which would favor a non-inflammatory fibrinous 
deposit. 

PERICARDITIS. 

The first effect of inflammation in the pericardium is to produce a 
reddening and pulpy thickening of the membrane, by the congestion of 
the bloodvessels and interstitial effusion of serosity. A beautiful reticu- 
lation of minute vessels is visible to the naked eye, and still better under 
a low power of the microscope ; both on the internal and external sur- 
face of the pericardium exudation on the free surfaces then follows, 
which, according to the constitution of the individual, is of a more or 
less plastic character. In the most active forms, the effused matter is a 
semi-fluid, organizable material of a yellowish hue, forming a reticulated 
or villous appearance, which must be attributed to the movements of the 
heart. Laennec has very correctly compared the appearance thus pre- 

1 Memoires de la Socie'te d'Observation, vol. i. p. 347. 

2 See Dr. Taylor's paper on the Causes of Pericarditis, in Medico-Chir. Trans., vol. 
xxviii. p. 468. 



PERICARDITIS. 



291 



sented, to that we see on quickly separating two slabs of marble, be- 
tween which a layer of butter was interposed. This plastic material 
gradually becomes organized, and we find minute red vessels projecting 



Fig. 138. 




A heart covered with plastic exudation, investing hoth the parietal and visceral layer of the pericardium, 
which has been cut open and reverted. An incision has been made through the false membrane over the left 
ventricle, to turn it back and show the subjacent muscular tissue. The lymph fringes the right auricle and 
coats the root of the aorta. 



into it; and as this process proceeds the two surfaces become intimately 
adherent to one another; the lymph loses its fluid constituents; it is con- 
verted into firm bands, connecting more or less loosely the visceral and 
parietal pericardium, which, according to their density and tenacity, 
indicate the period of their formation. If adhesion does not result, 
absorption may remove these appearances, and nothing but a general 
opacity or thickening of the pericardium remains ; or again, the active 
condition may be arrested after the formation of villi, and without the 
supervention of adhesion they may continue in a passive state, and pre- 
sent the appearance termed the hairy heart, the cor villosum. It is 
customary to quote as an instance of this a classical name ; the great 
enemy of Sparta, Aristomenes, was captured and killed on his third 
entry into Lacedsemon, and his heart is stated by Pausanias to have 
been found covered with hair. In a less sthenic constitution the effu- 
sion resulting from pericarditis will be of a more serious character; and 
we then find the pericardium more or less distended with a straw-colored 
fluid, in which flakes of lymph are discovered, while traces of lymphatic 
exudation are seen attached to the membrane with thin free ends waving in 
the fluid. We have seen the pericardium mount up from this cause to the 
second rib, and the quantity of serum varies from half an ounce to two 
quarts. In this case, as in the former, absorption may take place, leav- 
ing but comparatively slight traces of the previous disease, and the 
pericardium itself appears to adjust itself to the reduced quantity of its 
contents. 

A third form of exudation met with is of a purulent character, which 



292 PEEICAEDITIS. 

is of a more atjpic nature than the last. It is the least frequent, and 
is always associated with a large amount of serous effusion. It is chiefly 
met with in protracted cases, though Dr. Hope avers that even in the 
first stage a degree of milky opacity is observable in the serum, which 
may be attributed to an admixture of real pus. Hope is of opinion 
that even pus may, if not exceedingly copious, be sometimes partially 
absorbed, leaving only its solid parts to undergo ulterior changes. 

The serous effusion just spoken of must not be confounded with the 
dropsical accumulation of fluid, to which we should restrict the term 
hydropericardium, and which is a frequent accompaniment of general 
dropsy. In many cases of wasting disease we find a few ounces of 
serum in the pericardium, which we must refer to mere want of tone in 
the vessels, and which appears to be eliminated shortly before death. 
It is not associated with symptoms of inflammatory action ; and the 
fluid itself is a clear, amber-colored serum. In long-continued dropsy 
of the pericardium the heart is generally found contracted, and the 
muscular tissue anemic and of light-brown hue. Occasionally, an atro- 
phic condition of the sarcolemma results, which is characterized under 
the microscope by an absence of the striation seen in healthy muscle. 

In the exudation resulting from acute inflammation we occasionally 
meet with a small quantity of blood. Hemorrhage, independently of 
this cause of mechanical injury, or of rupture of the muscular tissue of 
the heart, is not met with in this locality as it is in the sac of the 
arachnoid. As regards the extent of the phlogistic process in the peri- 
cardium, it generally involves the entire surface of the membrane in 
acute cases; the chronic form, except as a sequel of the former, has a 
tendency to limitation, and its residuary effects are seen in the form of 
circumscribed white patches, either on the visceral or parietal portion, 
or of partial adhesions or isolated bands of false membrane. 

Pericarditis is not often an idiopathic disease. Dr. Latham, who was 
the first to notice its frequent complication with the rheumatic diathesis, 
has rarely met with it except in this connection. Andral gives six cases 
of pericarditis not connected with rheumatism, of which three w T ere un- 
complicated with any other morbid affection ; while Corvisart only met 
with five independent of rheumatism, which were all, excepting one, 
complicated with disease of other parts. The rheumatic complication 
is one found at all periods of life. Messrs. Rilliet and Barthez and Dr. 
"West look upon it as essential in young children; and all writers on the 
subject concur with regard to its frequency in adults, though the statis- 
tical results arrived at are not perfectly uniform. A further powerful 
predisposing cause is to be found in renal disease, and more especially in 
that form known as Bright's disease of the kidney. Dr. Taylor gives 
the following results of the analysis of the causes of thirty-eight cases 
of acute pericarditis: — 

There was rheumatism in 20 cases. 

Bright's disease in - . . 10 " 

Bright's disease doubtful, or other form of renal disease, in . 5 " 

Cyanosis 1 case. 

Extension of inflammation from adjoining tissues in 1 " 

37 



TUBERCLE. 293 

It follows that in examining the dead subject, we should, in all cases 
of pericardial disease, be particularly careful not to omit looking to'the 
condition of the kidneys, even if the symptoms during life were not 
such as to draw the physician's attention to these organs. Considering 
the degenerative character of Bright's disease, and its chronic course, 
we are justified in regarding it as a powerfully predisposing cause to 
inflammation of serous membranes, and particularly of the pericardium. 
The fact of the relation of the two diseases being established, will also 
assist us during life in discovering one by the indications of the other, 
as has already been the case in regard to rheumatic pericarditis; for the 
subjective symptoms of the latter are occasionally so slight, that but 
for our knowledge of the predisposing influence of rheumatism, we might 
not be induced to look for the evidence of heart disease. This remark 
applies with almost greater force to affections of the endocardium, which, 
as we shall have occasion to see, offers a yet greater proclivity to the 
morbid influence of the rheumatic diathesis than the external investment 
of the heart. 

The false membranes remaining after an attack of pericardial inflam- 
mation, may, unless absorbed, become the seat of similar changes, as we 
find them undergoing in other structures throughout the body. They 
present a metamorphosis into fibrous, cartilaginoid, and osseous tissue. 
The deposit of the latter occurs in smaller or larger patches; they may 
be numerous and distinct from one another, or they may unite to form, 
as in a preparation contained in Guy's Hospital (No. 1,448), a complete 
ring encircling the base of the heart. 



TUBERCLE. 

The relation of pericardial inflammation to definite dyscrasise is 
evinced negatively, by the absence of any proclivity of the membrane 
to be affected in tubercular disease. On theoretical grounds we might 
have been inclined to assume that the vicinity of the diseased lungs in 
phthisis, as well as the more immediate relation which would seem to 
exist between the blood circulating in the pulmonary and cardiac vessels, 
would have been a frequent source of disease in the latter, and the parts 
supplied by them. But while the meninges of the brain and the peri- 
toneum are constantly found to be the seat of tubercular deposit, the 
pericardium is remarkably free from it. Louis 1 has only found evidence 
of pericarditis three times in phthisis; and he details one case in which 
some semi-transparent gray granulations were found under the serous 
lamina of the pericardium, to which he attributes the pericarditis under 
which the patient was laboring. Dr. Hope states that tubercles are 
sometimes developed in the false membranes of pericarditis ; but neither 
does he himself give any positive evidence to that effect, nor have we 
succeeded in finding proofs of it elsewhere. It does, however, appear 
that the false membrane may itself become subject to simple inflamma- 
tion, which, from its known vascularity, is in accordance with the general 
theory of inflammation. 

1 Memoire sur la Pericardite, &c, 1826. 



29-i PNEUMOPERICARDIUM. 



CARCINOMA. 



Carcinoma affects the pericardium more frequently than tuberculous 
disease ; it occurs only in connection with a general cancerous cachexia, 
and a formation of similar growths in other organs ; the only variety 
met with is medullary carcinoma. According to Rokitansky, this 
secondary mass spreads itself in the form of an infiltration of the fibrous 
layer of the pericardium over a large portion of its surface, and presses 
upon and into the tissue itself, where it becomes developed into roundish, 
or flattened, or teat-like nodules. 



FATTY DEPOSIT. 

It is not uncommon to meet with an excessive deposit of fat upon and 
within the pericardium; it occurs in conjunction with general obesity, as 
well as in cases where there is little subcutaneous fat ; nor is it neces- 
sarily associated with true fatty degeneration of the muscular tissue of 
the heart, though we may at the same time find fat insinuating itself 
into the heart, so as to separate the muscular fasciculi from one another. 
It will be observed that accumulation upon the heart is largest in the 
horizontal sulcus, and that its distribution appears to bear a relation to 
the arrangement of the bloodvessels. 



PNEUMOPERICARDIUM. 

A condition of the heart rarely found until after death, and termed 
by Laennec pneumo-pericardium, consists in an effusion of air into the 
sac. Laennec states that he was able to diagnose its presence during 
life from the unusually clear sound yielded by percussion in the region 
of the heart, and by a sound of fluctuation accompanying the move- 
ments of the heart and of respiration. In the majority of cases, it is due 
to post-mortem decomposition of the pericardial fluid. The vital gene- 
ration of gas in the sac must be an occurrence of extreme rarity, since 
Rokitansky does not appear to have met with an instance. M. Briche- 
teau is quoted by M. Bouillaud 1 as having met with a case of hydro- 
pneumo-pericardium, in which a murmur resembling the noise of a 
water-wheel was heard during life, evidently connected with the alternate 
movements of the heart. The pericardium was found to contain a fetid 
effusion, and, on incision, the contained gas escaped with a lisping noise. 
During the present year (1852), a case of perforation of the oesophagus, 
which had formed adhesions to the pericardium, occurred in St. Mary's 
Hospital. The patient was a young woman under the care of Dr. 
Chambers, in whom the admission of air into the pericardium occurred 
shortly before death through the perforation; the pericardium was found 
much distended from this cause, when the post-mortem examination was 

1 Traite Clinique, &g., vol. ii. p. 472. 



FIBRINOUS CONCRETIONS IN THE PERICARDIUM. 295 

made ; and it was owing to this circumstance that the fibrinous layer, 
which had been deposited between the surfaces of the pericardium, had 
not given rise to any friction sound during life. 1 



FIBRINOUS CONCRETIONS IN THE PERICARDIUM. 

To complete the subject of the morbid contents of the pericardium, we 
have yet to advert to the presence of free bodies, which Rokitansky has 
met with in a case of pericarditis. He describes them as fibrinous, soft, 
yellow concretions, of the size of beans or almonds, and similar to the 
latter in shape ; which, he adds, would no doubt have eventually been 
converted into elastic, tough bodies of fibroid tissue. None of the 
authors whom we have been able to consult, record any similar case ; we 
may therefore assume that the actual occurrence of free bodies is a cir- 
cumstance of extreme rarity, and the above seems rather to be due to 
an accidental agglomeration of fibrinous flakes than to any other new 
production of tissue. 

1 The case is detafled in the Report of the Pathol. Soc. for 1852-3. 



CHAPTER XVIII. 

THE MORBID ANATOMY OF THE HEART. 

The close relation existing in disease between certain affections of 
the pericardium and endocardium would be a sufficient excuse for taking 
the affections of the latter into consideration at once. But it appears 
more convenient to follow the anatomical sequence, both because there 
is an undoubted relation between many morbid states of the serous 
envelop and the muscular substance, and because the pathology of the 
endocardium is a natural transition to the morbid anatomy of the car- 
diac valves and the bloodvessels. Much has been done of late to pro- 
mote our knowledge of cardiac disease, and the main result has been to 
withdraw many so-called functional diseases of the organ from this 
category, and to classify them with the known lesions met with in other 
tissues of the body which are more accessible to examination in life. 
It is more particularly in the sphere of degenerative changes, and their 
effects, that the advance has taken place; much yet remains to be done 
in the demonstration of the simple and primary forms of disease. 

Congestion of the heart may be assumed to exist in the early stages 
of several affections with which we become acquainted, when they inter- 
fere with the vital functions. We frequently find the heart of a dark 
color, and the veins overcharged with blood, as secondary effects of dis- 
turbance in the circulation; in the same way, we see an anaemic condi- 
tion of the organ manifested by pallor, and a flabby condition of the 
muscular tissue, in the train of long standing and debilitating disease. 



CARDITIS. 

Genuine carditis, ulceration, and abscess of the heart, are conditions 
of which but few cases are recorded. Of the former, Dr. Latham 1 
details a remarkable instance. It occurred in a boy, aged twelve years, 
who presented all the symptoms of acute cerebral disease, without any 
indications of the disorganization found after death. No vestige of 
morbid action was discovered in the brain, but the heart was the seat of 
the most intense inflammation, pervading both the heart and muscular 
structure. There was the ordinary evidence of recent pericarditis, and 
when the heart was itself divided, the muscular fibres were dark-colored, 
almost to blackness, loaded with blood, soft, and loose of texture, easily 

1 Lectures on Clinical Medicine, &c, 1845, Lect. xxv. 



CAKDITIS. 297 

separated, and easily torn by the fingers, and at the cut edges of both 
ventricles small quantities of dark-colored pus were seen among the 
muscular fibres. The internal lining was of a deep red color, without 
any effusion of lymph. A case which resembles the one just detailed, 
and which occurred in the practice of Mr. Salter, of Poole, is detailed 
in the twenty-second volume of the Medic o-Chirurgical Transactions. 
It affected a man aged fifty, who died after a short illness, in which the 
main symptoms were oppression and distress at breathing, inability to 
lie down, and a dull, heavy pain at the sternum. The pulse at the 
same time was eighty, and regular, and the action of the heart seemed 
natural. There was no serous or other effusion into the pericardium, 
nor any signs of disease in the valves or endocardium. The heart itself 
was somewhat larger than natural, and its substance of moderate firm- 
ness. The great deviation from the normal condition of the heart was 
to be found in the muscular condition of the left ventricle. Excepting 
a few lines in thickness on either surface, the left ventricle had entirely 
lost its muscular color; it was of lightish yellow hue, but still preserv- 
ing the fibrous character of muscle. From all the cut surfaces purulent 
matter could be scraped; in some parts absorption had taken place, 
leaving small cavities in the muscular substance, varying from the size 
of a pin's head to that of a small pea; these were all filled with pus. 
A third case of the same kind is related by Mr. Stanley in the seventh 
volume of the Medico- Chirurgical Transactions, p. 323, which occurred 
in a boy aged twelve. In purulent infection, when deposits of pus are 
found in the parenchyma of every organ of the body, the heart rarely 
presents similar appearances. It is a common thing to find the muscu- 
lar tissue in severe pericarditis of an abnormally dark color, and it 
seems probable that, in the cases alluded to, the primary disease lay in 
this membrane. In those rare cases in which an ulcer is found in the 
substance of the heart, and an abscess occurs in the muscular tissue, we 
may fairly assume local inflammation to have preceded, and in the cases 
which are presented by the records of pathological anatomy the appear- 
ances are generally mentioned as indicating such a process. In a case 
of general hypertrophy of the heart, accompanied by enormous dilata- 
tion of the mitral orifice, and diseased aortic valves, which was exhi- 
bited at the Pathological Society in 1847, by Dr. J. R. Bennett, an 
opening of the size of a quill was found in the ventricular septum; this 
was surrounded by ulceration, warty roughness, and thickening, and 
there were distinct traces of inflammation round the opening. Hemor- 
rhage into the substance of the heart is occasionally met with in small 
spots, in connection with pericarditis; but in cases of genuine cardiac 
apoplexy, as Cruveilhier terms effusion of blood into the substance of 
the heart, which must be considered in the same category as sponta- 
neous rupture of the organ, we almost invariably find fatty degenera- 
tion at and near the point, which has destroyed the uniform consistency 
of the organ. 

Before entering into the examination of this morbid condition, we 
must mention one undoubted residue of inflammation, which presents the 
appearance of fibrinous deposit, or an interstitial deposit of lymph. We 
meet with this in rheumatic subjects. The heart presents a feeble, flabby 



29S FATTY DEGENERATION. 

appearance, and spots of an irregular shape and a pale yellowish hue 
are found scattered through the tissue. The circumference of these 
spots is tolerably defined, or the deposit appears to follow the direction 
of the fibres. It may itself be associated with fatty degeneration, but 
the microscope sufficiently serves to distinguish it from this condition. 
It is found to consist of granular matter, within which nuclei and fibroid 
cells are imbedded, and oil-globules. This is entirely external to the 
muscular fibre, which commonly exhibit an atrophic condition in the 
immediate vicinity of the deposit. Dr. Hope 1 recognizes three varieties 
of softening occurring in the heart as a result of inflammatory action : 
a red, whitish, and yellow form. The red, he says, corresponds to the 
first stage of carditis, and is analogous to the inflammatory engorgement 
constituting the first degree of peripneumony ; the whitish corresponds 
with a more advanced stage, analogous to the second and third degrees 
of peripneumony, when a pale tint is produced by the absorption of the 
red particles of the blood, and by the presence of lymph and pus in 
variable proportions. The yellow variety he considers rather the result 
of chronic inflammation. These views are supported by Laennec, Bouii- 
laud, Corvisart, and other continental authors, who at the same time 
admit the distinct character of a fatty degeneration. The microscope 
has of late contributed much to unsettling these doctrines, inasmuch as 
the naked-eye view has been almost superseded, and, in some instances, 
we fear, to the detriment of true science. For, valuable as it is in 
analysis, if used exclusively it prevents that general coup d'oeil which 
embraces more than one morbid phenomenon, and which is necessary to 
the due appreciation of disease in its totality. We are induced to make 
this warning remark, because, in analyzing the records of the post-mor- 
tem appearances of heart-disease during the last six years, we find that 
almost invariably a fatty degeneration of the organ, or of individual 
parts, has been discovered; and this condition is one which is by no 
means limited to a certain well-defined disease, but is found to prevail 
so extensively that we cannot but look upon the molecular disintegration 
implied by it as a mere sympto%i of various elementary morbid states. 
It is undeniable that the appearance of minute vessels, e.g. of the brain 
in a state of fatty degeneration, as found in the vicinity of apoplectic 
clots, or in connection with atheroma of the larger arteries, closely 
resembles the appearance presented by vessels of the pia mater sur- 
rounded by or containing so-called exudation-matter in meningitis. In 
both instances, microscopic globules, of a highly refracting character, 
are the characteristic symbol. The fibre of the heart, when affected in 
this manner, presents a similar appearance. 



FATTY DEGENERATION. 

The degeneration may be traced through various stages. It com- 
mences as an atrophic condition, in which the fibre loses its sharp edges, 
and the strise, so well seen in the healthy heart, disappear. One or 

1 A Treatise on Diseases of the Heart, &c., 3d edit. p. 333. 



FATTY DEGENEKATION. 



299 



more oil-globules successively appear, until the whole fibre is occupied 
by them ; its outline is broken, and in the highest development the fibres 
appear almost fused together into a confused, more or less opaque, mass, 
in which nothing of the original tissue can be traced. This molecular 
deposit of oil in the fibre is often accompanied by a generally adipose 
condition of the organ, and a layer of fat on the surface ; but not neces- 
sarily so, and we must be careful not to infer that the heart is in a state 
of fatty degeneration because it is surrounded by adipose tissue. The 
fat may insinuate itself between the muscular fasciculi and fibres, and 
yet no change in the latter take place. The large circular fat-cell, with 
its sharp boundary of 5 Jo^ n °^ an ^ ncn ^ n diameter, when seen under 
the microscope, occupies the former position, and cannot be mistaken 
for the minute oil-globule, which varies from a microscopic point to 
5 qJq ^th of an inch, and is confined to the interior of the sarcolemma. 

The heart affected with fatty degeneration has lost the firm muscular 
appearance which characterizes it in health, and presents a pale, yel- 
lowish, buff color, either throughout or limited to individual parts. 
When cut into, a greasy stain is often left on the knife, though the 
absence of this circumstance must not be looked upon as an indication 
that the heart is not degenerated. The left ventricle and the columnse 
carneae are most liable to be thus diseased ; next in order the right 
ventricle and right auricle, while the left auricle is least frequently 
involved. Dr. Quain, 1 to whom we are indebted for a clear resume of 
the whole subject of fatty degeneration of the heart, has found that in 




Specimens of fatty degeneration of the heart. 

A. Heart-fibres taken from the columnse carneae of the mitral valves of a young woman, get. 30; the fatty 
degeneration was scarcely observable in the ventricle, where the fibres still retained their striae. 

B. An extreme case of fatty degeneration, showing an entire conversion of the muscular fibre into oil- 
molecules, still retaining a linear arrangement. It is taken from the right ventricle of an old gentleman, 
who had Bright's disease of the kidney and pulmonary phthisis, and was affected with fits during the last two 
years of his life. 



twenty-two cases, in which the seat of the disease was expressed, the 
two ventricles were affected in ten, the left alone in eight, and the right 
alone in four. Rokitansky describes three forms of fatty degeneration 
of the heart ; the first two are varieties of fat-deposit upon and within 

1 Medic o-Chir. Trans, vol. xxxiii. p. 121. 



300 FATTY DEGENERATION. 

the heart, external to the muscular fibre to which we have alluded above, 
and to which, with Dr. Quain, we would apply the term fatty growth, 
while the term fatty degeneration should be confined to that change in 
the muscular fibre which we have just described, and which constitutes 
Rokitansky's third form. The deposit and the degeneration may coin- 
cide, but there is no definite relation between the occurrence of the 
two. 

The frequency with which fatty degeneration of the heart occurs 
among the patients that present themselves in a London hospital, may 
be inferred from the circumstance that Dr. Ogle has met with it in 100 
out of 143 post mortems, in which he noted the microscopic appearances 
of the organ ; a circumstance sufficient to rivet the attention of nosolo- 
gists upon the heart, in order to determine with more accuracy than we 
at present can bring to bear, the incipient morbid conditions to which 
this state is due. It is essentially a disease of middle and advanced 
life ; and is, we may say, invariably associated with a fatty condition of 
other organs, more especially of the liver, the spleen, and the arterial 
system; in this is borne out the observation of Dr. Latham, that ex- 
cepting those cases in which the damage done to the heart could be 
clearly traced to some distinct attack of accidental disease, his records 
of dissections do not supply him with a single instance of a person re- 
puted to die of disorganized heart and its consequences, in whom, after 
death, other parts were not also found disorganized. And, he con- 
tinues, the kind of disease in other parts has been such as could in no- 
wise have been derived from the heart, but must have grown out of 
special morbid processes within themselves, whether prior or subsequent 
to, or simultaneous with, the disease of the heart. 

Dr. Quain concludes, from the circumstances, that when muscular 
tissue is exposed to certain influences, such as a stream of running 
water or the action of dilute nitric acid, it assumes appearances identical 
with those of fatty degeneration, that the processes occurring in the 
dead meat and the living heart are identical. We are willing to admit 
the analogy, but we are of opinion that the uniform evidence of a de- 
generative tendency throughout the system, accompanying the fatty 
heart, is a strong proof of the ultimate cause residing in the organs 
and function of nutrition. The circumstance of the coronary arteries 
being almost invariably atheromatous, or in a state of ossification, is 
rather corroborative of the view, for we are not justified in assuming a 
primary and idiopathic affection of these vessels. Whatever may be 
the theory of the disorganization, its existence and frequency is suffi- 
ciently established, as well as the fact of its being the cause of further 
changes in the muscular tissue of the heart, which are a common source 
of suffering and death. Syncope and angina pectoris during li e, are 
among the effects of fatty degeneration of the heart and diseased 
coronary arteries; apoplectic effusion into the substance of the organ, 
rupture, dilatation, and aneurism of the heart, are found in constant 
connection with this affection. 






APOPLEXY AND RUPTURE OF THE HEART. 301 



APOPLEXY AND RUPTURE OF THE HEART. 

Without a knowledge of this change, which has taken place in the 
tissue, and precedes the occurrence of these accidents, it is impossible 
to offer any rationale for them ; but now that we are acquainted with 
the fact that the muscular fibre is degenerated at certain parts of, or 
throughout the organ, it is easy to understand that, under given circum- 
stances, requiring an unusual effort in the heart, the weakest point will 
yield, and give rise to effusion of blood. It is difficult to offer an ex- 
planation for those cases in which the rupture appears to have occurred 
during perfect rest ; but it is not unreasonable to suppose that, when 
patients have died from this cause, while reposing in their beds, a sud- 
den movement of the body may have been the immediate cause of the 
accident; much in the same way as we see, in syphilitic and other ca- 
chectic states, the bones become so friable as to be fractured from the 
same trifling cause. There is no essential difference between those 
cases in which the hemorrhage seems confined to the muscular tissue, 
and those in which, owing to a laceration of the pericardium and endo- 
cardium, a passage is established by which the blood flows into the 
serous sac. In the latter case, we find the pericardium, on opening the 
body, distended with fluid blood, or, if the individual has survived some 
time after the accident, the blood is partly coagulated. The rent varies 
from an inch in length to a minute orifice ; it frequently runs into the 
septum, and occasionally we find an accompanying rupture of the 
columnee carnese. The left ventricle is by far the most frequent seat 
of these disruptions ; we find that six of the seven cases of spontaneous 
rupture of the heart, detailed in the Reports of the Pathological Society 
of London, occurred in the left ventricle, and only one in the right. 
An analysis of these cases also shows that the prevailing impression 
that the anterior surface is more liable than the posterior to become 
lacerated, is erroneous ; five having occurred on the posterior, and two 
on the anterior walls of the heart. In all there was fatty degeneration, 
most marked at the seat of injury ; the coronary arteries were found 
in an atheromatous or ossified condition, in the five cases in which they 
were examined ; the average age of the sufferers was 69J years. A 
rather different result is obtained by an analysis of cases of rupture of 
the heart, following mechanical injury, without penetrating wounds ; 
here, there is no suspicion of fatty degeneration, and a different ex- 
planation must be sought for, to account for the seat of the rupture, 
which appears to vary as much as the injury itself. We find that of 
five cases of this description, in all of which there was no penetration 
of the heart's substance from without, one occurred on the posterior 
surface of the left ventricle, one on the posterior surface of the left 
auricle, two on the anterior surface of the left auricle, and one on the 
anterior surface of the right ventricle. Here, the left auricle was three 
times affected, and each of the ventricles once. From what has pre- 
ceded, it may be gathered that we do not take Dr. Hope's view, that 
ulceration is the main cause of rupture of the heart; a solution of con- 
tinuity of the lining membrane of the heart from this cause, is, as we 



302 APOPLEXY AND RUPTURE OF THE HEART. 

shall have occasion to mention, when considering endocardial disease, 
an occurrence of extreme rarity, and it does not appear to bear any 
direct ratio to rupture, though it may give rise to gradual perforation. 

Rupture of the heart is generally immediately fatal ; instances are, 
however, recorded, in which the patient recovered from the first shock 
and survived for several hours; in these cases, nature is found to have 
made an effort at repair, in the shape of a film of lymph, exuded between 
the torn surfaces. 

Gangrene of the heart is a subject alluded to by pathologists, but it 
does not appear that any authentic cases of its occurrence are recorded. 
Dr. Copland looks upon it as manifestly a post-mortem alteration, acce- 
lerated by a depraved habit of body. We may, therefore, at once pass 
to the consideration of two conditions which are very frequent, and 
which are nearly allied to one another, hypertrophy and dilatation of 
the heart. 



CHAPTER XIX. 

HYPERTROPHY OF THE HEART. 

In determining the existence of hypertrophy of the heart, we must 
attend to two preliminary points; first, we must ascertain whether there 
is an absolute increase of the total bulk, as compared with hearts of 
healthy individuals of the same age and conformation ; and secondly, 
whether the relative size of the walls of the different cavities has altered. 
Next, it will be well to inquire into the relation existing between the 
walls of the cavity and its capacity, and it is also necessary to remove 
the contents, fluid or consistent, that may distend the cavities, before 
we form our estimate. Laennec suggested that the doubled fist of the 
individual might be taken as a rough measure of the size of his heart, as 
he found, that, in health, the two corresponded in their dimensions; 
there is no objection to retaining this indication, to assist our judgment, 
when more accurate determinations are not at our command. The weight 
of the healthy adult heart varies from eight to ten ounces, while, in 
hypertrophy, it is found to rise to as much as five pounds. 

At the same time, we must also bear in mind the fact, sufficiently 
well determined by Bizot, 1 that there is a progressive increase in the 
dimensions of the heart, from infancy upwards ; a circumstance that does 
not, at first sight, appear to tally with the general law of involution, but 
will, in many instances, probably, find an explanation in so-called fatty 
degeneration. The following table shows, at a glance, the results arrived 
at by that inquirer : — 





MALES. 








FEMALES. 








" 


a 


<w 


-1-3 




m 


a 


Vi 


u 




"8 




O . 


ci 




a 




o . 


sj 




o 






93 




o 






a 




'&•£ 


u 
a 


CO o 

u a 


A 




"S^ 


^ 


il 






P <U 


z> . 


n.9 


<— » 




P a> 


o 


P .s 


Vi m 




K 


A X 


a> ,-i 


© o 




it a 




O -H 


C i> 


Age. 


SI 


<sl 


&B 


K.S 


Age. 


og 


°1 


&.s 


a.S 




J* 


■a""* 


a-s 

P e3 


J.S 










|5 




a 

p 


J 


-P..P 
O 


o 
H 




a 


to 

a 

o 






1—4 


7 


22|- 


27 


lOf 


1—4 


8 


22f 


251 


101 


5—9 


3 


311 


33 


12f 


5—9 


10 


26f 


29 


ll T 3 ff 


10—15 


3 


34 


37 


14 


10—15 


5 


29| 


31i 


19.2. 


16—29 


18 


42ft 


45j§ 


171! 


16—29 


14 


38f 


42 T \ 


17f 


30—49 


23 


43A 


47H 


17ft 


30—49 


27 


41ft 


44ft 


14^f 


50—79 


19 


451-f 


52|f 


18ft 


50—89 


19 


42ft 


46H 


16ft 



1 Memoires de la Soci^te d'Observation, torn. i. p. 262. 



304 HYPERTROPHY OF THE HEART. 

According to this table, there is an uniform increase in all the dimen- 
sions of the heart, from infancy to old age, with one exception, viz: in 
females after the age of 30, where there is a falling off in the thickness 
of the organ, the other dimensions continuing to increase. The heart 
appears, subsequently to recover itself, and again to follow the general 
law, but not sufficiently to attain a thickness proportionate to that in 
the male heart of the same age. Mr. Bizot's measurements are taken 
vertically, from the apex to the base, round the base at the junction of 
the auricles and ventricles, and at the thickest part of the left ventricle. 

The part most commonly affected with hypertrophy is the left ventri- 
cle, and even when other portions of the heart have acquired an increase 
of size, there is still an increase upon the relative dimensions of the 
walls of the left ventricle. Bouillaud 1 gives the following measure- 
ments of an adult normal heart, weighing between eight and nine 
ounces : — 

Inches. 
Average circumference at base . . . . . . 8 to 9 

do. longitudinal and transverse diameters ... 3^ 

Lines. 
Average thickness at base of left ventricle . . . . 6 to 7 
do. do. do. right do. .... 1\ 

do. do. do. left auricle .... 1 \ 

do. do. do. right auricle .... 1 

In health, the relative proportion of the thickness of the left and right 
ventricles is as 1 : 3 ; if we bear these facts in mind, they will assist us 
in determining any relative changes, and the weight of the organ will 
establish the fact of an absolute augmentation of bulk. 

Hypertrophy occurs in three forms, to which Bertin was the first to 
draw attention, and his classification has been adopted by subsequent 
writers. In the first, which is termed simple hypertrophy, the walls of 
the heart are thickened, while the cavities retain their normal dimen- 
sions ; the second, eccentric or aneurismal hypertrophy, presents an 
augmentation both of the lumen of the cavities and of the substance of 
their parietes ; and in the third, which has received the name of con- 
centric hypertrophy, the former is reduced, while the latter is alone 
increased. The last variety, probably, has no existence as a morbid 
condition, but is, according to the showing of Cruveilhier and Dr. Budd, 
a post-mortem effect, an evidence, simply, of the powerful tonic contrac- 
tion of a robust heart. The former writer observed that it occurred in 
almost all persons decapitated by the. guillotine, and the latter has 
pointed out that in all concentrically hypertrophied hearts the ventricle 
may be easily dilated by means of the fingers, and always dilates of 
itself, when the rigor mortis goes off. The simple and eccentric forms, 
then, are the two which alone constitute actual cardiac disease. 

A priori, we should expect to meet with the former, very frequently, 
as a mere effect of stimulated nutrition, since the heart's action is so 
constantly abnormally increased, and its powers unduly taxed; and also 
because, according to Bizot, there is an uniform increase of the heart 
from birth to the grave; but such cases are the exception, while, in the 

1 Traite Clinique des Maladies du Coeur, vol. ii. p. 559. Paris, 1835. 



HYPERTROPHY OF THE HEART. 305 

majority of instances, some lesion may be discovered in the heart, or 
the larger bloodvessels, which, by impeding the current of the blood, 
gave rise to unusual efforts on the part of the heart, and thus to hyper- 
trophy of its tissue ; in the same way as we see the coats of the urinary 
bladder enormously augmented in bulk, when a long-standing stricture 
has daily called for violent contractions for the removal of the obstacle. 

The left ventricle in either form of hypertrophy is the part that is 
most frequently affected ; next in order, the right ventricle, and, lastly, 
longo intervallo, the auricles. There is not necessarily a relation be- 
tween the increased thickness of the walls of a cavity and of the columnae 
carneae ; the former may be themselves only thickened in some parts, 
while in others they retain their normal size; and again, we occasionally 
find the trabecule much enlarged, while the proper walls present but 
little variation. Hypertrophy of the heart necessarily alters, more or 
less, the relation between the thoracic viscera, a point of importance to 
the practitioner, as it also gives rise to modifications in the form and 
direction of the organ, which generally becomes more globular and 
spherical, while its apex is tilted up, and the long diameter occupies a 
more transverse direction than in health. 

In uncomplicated hypertrophy, where we have to deal with no morbid 
product, but that of an increase in the amount of muscular fibre, the 
muscular tissue is of a deeper red than usual, and its consistency is 
increased ; but the hypertrophy may be the result of a degenerative 
process, or a degeneration may have set up in the organ, subsequent to 
the hypertrophy having been established ; the color may then be of a 
brownish tint, or present yellowish or fawn-colored spots, while the con- 
sistency is generally reduced. In the former case, we find the characters 
of voluntary muscular fibres more strongly marked than usual; the trans- 
verse striae are more defined, and the edges have a sharper outline ; in 
the latter, these characters are more or less altered, and we meet with 
further traces of the specific alteration. An analysis of the cases of 
fatty degeneration collected by Dr. Quain, 1 shows that the prevailing 
condition, of the heart accompanying this state is one of hypertrophy, 
whether primary or secondary we are not prepared to determine, though 
it appears very probable that the change known as fatty degeneration 
is the result of various morbid processes, inducing a disintegration of 
tissue. In the thirty-three cases of Dr. Quain's first series, the heart 
is stated to be enlarged in twenty-one ; in six the organ was of a normal 
size; in four the dimensions are not stated; in one there was dilatation 
without hypertrophy, and only in one was the heart decidedly smaller 
than usual. 

The causes inducing hypertrophy are essentially of two kinds; "in 
the one kind," to use Dr. Watson's terms, "there is some mechanical 
obstruction to the exit of the blood from one or more of the cavities; a 
constricted state of the orifices is the most common condition. In the 
other kind, without any such mechanical drain or bar to the fluid, there 
is something to hinder the free and sufficient play of the organ, an ad- 

1 Medico-Chir. Trans, vol. xxxiii. 

20 



806 HYPERTROPHY OF THE HEART. 

hering pericardium, it may be, or mal-position of the heart. The causes 
of hypertrophy may, therefore, be situated within the heart itself, or 
without and beyond it ; but in all those cases in which the effect of the 
hinderance or obstacle is to detain the blood in one or more chambers, 
the hypertrophy will be likely to be accompanied by dilatation, and 
generally speaking the hypertrophy and dilatation result from disease 
in some part, which lies beyond the affected chamber in the order of the 
circulation." The largest hypertrophied heart, however, which we have 
met with, was one of the latter class, in which no such obstacle could be 
discovered. The specimen, which was taken from a middle-aged man, 
is preserved in the St. George's Hospital Museum, and weighed, when 
removed from the body, 5 lbs.; the left ventricle is enormously hyper- 
trophied, and very much dilated at the same time ; but beyond this 
increase in the size of the heart, no morbid appearances are perceptible 
or on record ; the valves are all perfectly healthy. 

Insufficiency of the valves, by whatever cause produced, is one of the 
most frequent excitements of hypertrophy ; and as the former lesion 
prevails most on the left side, it agrees with the fact that the left ven- 
tricle is the part most commonly affected. Indirectly, the passage of 
the blood from the right side may be thus influenced, and an increase of 
the walls of that part result. Impediments occurring in the course of 
the arterial system at a greater or less distance from the heart act in 
a similar manner, but, as may be supposed, in the ratio of their proximity 
to the heart. It is thus that we account for the complication of hyper- 
trophy, more especially of the left ventricle, with aneurisms. Obstruc- 
tions in the capillary circulation, though less frequently, give rise to 
hypertrophy ; this cause is found to obtain chiefly on the right side of 
the heart, partly, we may fairly conclude, on account of the greater 
vicinity of an extensive capillary system in the lungs to this portion of 
the organ than exists in relation to the systemic side. The most marked 
case of hypertrophy of the right ventricle which we ourselves have wit- 
nessed, occurred in a child of one year and a half, who had been long 
subject to pneumonic attacks ; and in whom, after death, the whole of 
both lungs were found studded with small lobular abscesses. The sub- 
stance of the right ventricle was increased in thickness by one-third, as 
compared with the left ventricle. An undeniable influence must be also 
attributed to inflammatory affections of the endo and exo-cardium, as 
well as to chronic inflammatory conditions of the muscular tissue of the 
heart; though the actual demonstration of the latter is a point yet to be 
effected, unless we assume that fatty degeneration may be the result of 
a phlogistic process. The manner in which pericarditis gives rise to it, 
is by causing partial or general adhesions, and thus preventing the free 
contraction of the muscular tissue. Endocarditis most commonly gives 
rise to hypertrophy, by inducing changes in the valvular apparatus, and 
thus affording impediments to the sanguineous current. 

In the thirty-fifth volume of the Medico- Chir-urgical Transactions, 
Dr. Barclay publishes a list of ninety-two cases of heart disease, taken 
from the post-mortem records of St. George's Hospital, of which we 
have made an analysis with regard to the relation of frequency of hyper- 



DILATATION OF THE HEART. 307 

trophy and dilatation ; and we find that while the muscular tissue of the 
heart presented a state of hypertrophy only in twelve cases, there was 
hypertrophy combined with dilatation in forty-six, and only fourteen in 
which the latter condition was observed alone. 



DILATATION OF THE HEART. 

If in hypertrophy of the heart we in many cases see an effort of 
nature to adapt the organ to peculiar requirements entailed upon it by 
morbid conditions, and therefore would, a priori, expect to find it fre- 
quently accompanied by dilatation, we fail to discover this tendency 
where the latter condition occurs by itself. This form of dilatation is 
necessarily associated with an attenuated state of the muscular parietes, 
and may, therefore, be considered as synonymous with atrophy of the 
organ. Hypertrophy, with dilatation, corresponds to the condition to 
which the older authors applied the term active dilatation ; while dilata- 
tion, associated with a diminution of the fleshy parietes, was known as 
passive dilatation. The two conditions have also been respectively called, 
by Corvisart, active and passive aneurism of the heart. These various 
terms show that the subject itself has not been established on a settled 
basis ; and they certainly only tend to increase the embarrassment of the 
student. The less our nomenclature involves disputed theories the better, 
and as long as we are unable to base our terminology upon a knowledge 
of the proximate causes of disease, it is wiser to employ names that are 
derived from the most prominent symptom. In the present instance, we 
shall continue to use the term dilatation to designate a distinct class of 
morbid changes in the heart, and we shall separately consider the two 
varieties under which it occurs, the general and the partial form. 

When, as Bouillaud remarks, the blood ceases to exert its stimulant 
and irritant influence upon the heart, and there are causes tending to 
enlarge its cavities, we find dilatation without hypertrophy ; the blood in 
that case does not augment the molecular nutrition of the organ, but 
appears to act simply according to the laws of hydrostatics as a forcing 
power. That it should, however, at any time be able to cause a change 
in the cardiac cavities, necessarily presupposes an alteration in the 
power of the heart, and in the cohesion of the muscular tissue. The 
ultimate cause of these conditions may be supposed to reside in the nerv- 
ous or vascular system, or in both conjointly. 

The parietes of a dilated heart may be attenuated to an extreme de- 
gree ; the thickest part of the left ventricle may be reduced to two lines 
in diameter, while at the apex the muscular substance may have disap- 
peared entirely, so that the endocardium and pericardium are in opposi- 
tion ; at the same time, we find a corresponding diminution in the 
thickness of the columns carnese. In one point there is a characteristic 
difference between hypertrophy and dilatation, independently of the 
nature of the lesion. This is in regard to the part affected. The left 
ventricle is most frequently attacked with hypertrophy, while we meet 
with dilatation most commonly in the right ventricle. It has been stated 
that the female sex are most prone to dilatation, and males to hypertro- 



308 DILATATION OF THE HEAET. 

phy ; we do not find this to be the case. On analyzing the ninety-two 
cases of heart-disease collected and reported in the Medico- Chirurgical 
Transactions, by Dr. Barclay, 1 with a view to determining this question, 
we find that, of fourteen cases of dilatation, six occurred in females, 
and eight in males ; of sixteen cases of hypertrophy alone, seven were 
women, and nine men; of forty-six cases of hypertrophy combined with 
dilatation, seventeen were females, and twenty-nine males. On a rough 
average it therefore appears that in each variety there is a preponder- 
ance of about one-third on the side of the latter. Dilatation, as Dr. 
Hope remarks, takes place more in the transverse than in the longitu- 
dinal direction of the ventricles, and it accordingly communicates to the 
heart an unusually spherical form, the apex being rounded off in such 
a manner as frequently to be scarcely distinguishable. 

Dilatation affects the auricles more frequently than hypertrophy ; 
however, we must be careful in not hastily assuming a diseased condi- 
tion, where its semblance is owing merely to distension. This is par- 
ticularly the case with the right auricle, which very commonly appears 
much dilated, owing to the accumulation of blood taking place on this 
side of the heart in articulo mortis. If on removing the contents the 
cavity presents its normal appearance, we consider it to have been 
merely mechanically and temporarily distended; if the enlargement is 
persistent, we may look upon it as the result of morbid action during 
life. A dilatation of the right side of the heart is met with in con- 
nection with patency of the foramen ovale. A case of this kind was 
exhibited by Dr. Lloyd, 2 before the Pathological Society. It occurred 
in a boy aged sixteen, who had been subject to bronchitis, with tempo- 
rary cyanosis. The right auricle was much dilated, and the right vent- 
ricle was dilated and hypertrophied, while the left side presented the 
normal appearances. 

The preceding remarks apply mainly to general dilatation ; partial 
dilatation, or aneurism of the heart, is, according to Rokitansky, whose 
views on this subject are particularly lucid, a condition depending espe- 
cially upon an inflammatory state of the endocardium and the muscular 
tissue at the point affected. The following abridged view of this writer's 
opinions is the best account of the matter that we have to offer to our 
reader. Rokitansky assumes the existence of two distinct forms of 
cardiac aneurism. The first — the acute and rarer form — depends upon 
a laceration of the diseased endocardium, and adjoining muscular tissue, 
through which the blood passes ; and the power of resistance being 
diminished at the point, a pouch is established, a fringed margin of 
endocardium is found at the entrance, and the blood deposits its fibrin 
witbin, while the margin becomes fringed with vegetations. Rokitansky 
has never seen a case in which the walls of an aneurism, formed in this 
manner, had become consolidated into a fibroid, callous tissue. In all 
the cases examined by him, the aneurismal formation was of recent date, 
having existed only a very inconsiderable period after the endocarditis, 
during the continuance of which it had originated. The second form 

' Medico-Chir. Transact, vol. xxxv. 

2 Reports of Pathological Society, 1848, p. 223. 



DILATATION OF THE HEART. 309 

is the more remote effect of an inflammatory condition of the investing 
or lining membrane, or of the muscular parietes of the organ. This 
induces the development of a fibroid tissue, replacing, or, we should 
rather say, causing the absorption of, the muscular fibre. The new 
tissue contracts, the parietes lose their power of resisting the pressure 
of the blood, and a circumscribed dilatation ensues. 

The aneurism varies much in size, from that of a pea to that of the 
heart itself; it does not necessarily present an enlargement at the sur- 
face, nor does it appear to possess an inherent tendency to increase ; 
thus, in a case presented to the Pathological Society by Dr. Jenner, 1 in 
1848, an aneurism was found of the size of a filbert at the apex of the 
left ventricle. Though there was no muscular substance over the ex- 
tremity of the sac, it did not project beyond the external wall of the 
ventricle. The existence of the aneurism in this instance was traced 
back to two years previous to the death of the individual. A few old 

Fig. 140. 




Aneurism of the left ventricle, formed by dilatation of a circular portion of the anterior wall, in a girl aged 
19. The pouch was filled with a laminated coagulum; its mouth was narrow, round, and smooth, and its 
parietes consisting apparently of endo and pericardium, with small deposits of a soft yellowish substance 
between them. The disease had probably commenced 18 months before death. — St. Bartholomew's Museum. 
Series xii. No. 53. 

slight adhesions binding the apex of the ventricle loosely to the free 
pericardium, indicated a previous inflammatory condition at the affected 
point. It appears that the healthy tissue of the organ possesses in 
many instances an inherent power of neutralizing the evil effects which 
might be expected to result from a local loss of resisting power in the 
parietes ; otherwise, it is difficult to understand how a cavity can be 
hollowed out in their substance without seriously impairing the con- 
tractile power. We sometimes find cases in which the thinning is not 
quite so definitely circumscribed as Rokitansky describes it, and where 
it yet proceeds to an extreme degree. Thus, we have seen a case of 
enormous dilatation of both ventricles without hypertrophy, in which 
the apex of the left ventricle was thinned to the size of a sixpence (St. 

1 Report of the Pathological Society, 1848-9, p. 89. 



310 ATROPHY OF THE HEART. 

George's Museum, 1842-62). Partial aneurisms are not necessarily 
solitary, but there may be two or three, which may, as they progress, 
intercommunicate. Next to the apex of the left ventricle we find its 
base, and, third in order, the septum ventriculorum liable to be thus 
affected ; in the latter case the bulging is towards the right side of the 
heart. Considering that there is a point in the upper part of the sep- 
tum, at which normally there is no muscular tissue to maintain the 
separation of the two cavities, we should be led to expect the occurrence of 
aneurism more frequently at this point ; but in ordinary circumstances 
the balance of the circulation suffices to prevent this result. When this 
form of aneurismal dilatation extends to such a degree that an opening 
and communication between the ventricles results, we have to deal with 
what Dr. Thurnam has termed the varicose aneurism ; it is a condition 
analogous to a congenital state, not unfrequently met with, in which the 
ventricular septum is more or less defective. 

The contents of the cardiac aneurisms vary ; we find in them fluid 
blood, more or less decolorized, sanguineous coagula, or laminated fibrin- 
ous deposits, resembling those found in arterial aneurisms, and present- 
ing similar microscopic appearances. 

The male sex and mature age offer a greater proneness to aneurism 
of the heart than the female sex and youth; the proportion with regard 
to sex is about 1 to 3 ; Hasse states that of forty-seven cases thirty-five 
were men and twelve women; and of forty-two cases, ten referred to 
individuals under thirty, and thirty-two to older persons. 



ATROPHY OF THE HEART. 

In introducing the subject of dilatation, we observed that it was essen- 
tially an atrophic condition. Atrophy of the heart is also met with in 
the shape of a mere reduction of size, either as a result of wasting dis- 
ease or as a congenital vice. Three extreme cases recorded by Burns 
probably belong to the latter variety; in one instance, he found the 
heart of an adult as small as that of a new-born infant, and in another 
the heart of a female, aged six-and-twenty, was no larger than of a 
child of six years. Bouillaud describes a case of an old woman of 
sixty-one minutely, who died of acute peritonitis, in whom the heart 
was a third smaller than in the normal condition, or about the size of 
the heart in a child of ten or twelve. The surface was furrowed and 
presented milk spots, the remains of former pericarditis ; the cavity of 
the left ventricle was scarce large enough to contain a pigeon's egg, and 
its parietes were only three lines in thickness. In phthisis, there is a 
uniform diminution in the size of the heart; in no other maladies is this 
so much the case, as illustrated by the following measurements given by 
Bizot 1 of the heart in the adult: — 

1 M6moires de la Societe d'Observation, vol. i. p. 277. 



MORBID GROWTHS. 



311 



MALES. 


FEMALES. 


Age 16 to 79 
years. 


Length of 
heart lines. 


A 2 

g-s-a 


CO 

3 3 


Age 16 to 89 
years. 


3.3 


Circumfer- 
ence of 
heart lines. 


03 

5 3 


57 
Phthisical. 

65 
Non- 
Phthisical. 


42A 

4&A 


47^ 
50ff 


15]i 
18H 


— 


39f 

43 


41*V 
47|| 


16A 



MORBID GROWTHS. 

The adventitious and heterologous products found in the muscular 
tissue of the heart are almost all pathological curiosities, with the ex- 
ception of the fatty metamorphosis to which we have already alluded. 
Acephalocysts are occasionally met with, as also the cysticercus and 
echinococcus. A well-marked instance of the latter was presented to 
the Pathological Society by Mr. Ward, in 1847, and the preparation is 
still preserved in the Museum of the London Hospital. 1 In this case 
no trace of the entozoon was discovered in other viscera. A remarkable 
case in which a cyst containing hydatids was found in the substance of 
the heart, is recorded and delineated by Mr. Evans in the seventeenth 
volume of the Medieo-Chirurgical Transactions. It occurred in an un- 
married female, about forty years of age, who, during the winter pre- 
ceding her death, had been subject to palpitation and angina pectoris. 
The cavity of the pericardium was found to be coated with a layer of 
coagulable lymph over a small extent of its front surface ; the apex of 
the heart was lost in a considerable tumor, apparently an elongation of 
the heart itself, and covered on all sides by pericardium. The new 
growth was found to project into the cavity of the right ventricle, was 
smooth, globular, and about three inches in diameter. It contained 
numerous hydatids from the size of a pea to a pigeon's egg ; their in- 
terstices being filled up by a soft, curd-like, yellow substance. The 
hydatids were precisely the same as those found in the liver. The 
trichina spiralis has not been met with in the heart. Ossific deposits 
are recorded, but they seem invariably to proceed from the endocardium ; 
and we shall return to the subject in connection with the diseases of this 
membrane. Both Corvisart and Hope give cases of portions of the 
heart being converted into cartilage : we should be inclined to assume 
that if these cases had been subjected to microscopic examination, the 
tissue would have proved fibrous rather than cartilaginous. Tubercle 
and cancer occur in the heart, but only when the respective dyscrasiae 
are very strongly marked ; the centre of the vascular, in this respect, 
differs much from the centre of the nervous system. Of the two, cancer 
is the more frequent ; it occurs in the medullary and melanotic varie- 



Report of Pathol. Soc. 1847-8, p. 225. 



312 MORBID GROWTHS. 

ties, and either by infiltration or in the form of isolated tumors. An 
exceptional case, as proving the occasional evolution of cancer in the 
heart, is recorded by Mr. Travers. 1 On the anterior apex of the heart 
of a gentleman, who died suddenly with symptoms of angina pectoris, 
and whose body he examined with Mr. Parrott, of Clapham, he found a 
fungoid growth, elevated, and of the diameter of a shilling ; it had the 
true pulpy character. There was no ulceration, nor any correspond- 
ing appearance in the loose pericardium or elsewhere. The internal 
membrane was unchanged, except some earthy deposits about the aortic 
valves. 

1 On the Local Diseases termed Malignant. Med.-Chir. Tr. vol. xvii. p. 854. 



CHAPTER XX. 

MORBID ANATOMY OF THE ENDOCARDIUM. 

It has required the multiplied observations of numerous laborers in 
the field of pathology to establish the true nature and importance of 
endocardial affections; Laennec and J. P. Frank were among the first 
to draw attention to inflammatory conditions of the endocardium, but 
we owe the more correct appreciation of the subject to Bouillaud and 
Dr. Hope. The pathology of the endocardium is as significant in re- 
gard to its primary, as it is with regard to its secondary lesions. The 
membrane is analogous to that lining the bloodvessels ; it consists of a 
layer of epithelium, investing a fibrous tissue, between which and the 
muscular fibre of the heart there is a layer of elastic cellular tissue; it 
is in the latter that bloodvessels ramify, and through them the nutrition 
of the surface-laminse becomes affected, in disease as well as by the direct 
influence of the blood contained in the cavities of the heart. It is 
necessary to bear this double relation in mind, as, without a due per- 
ception of these facts, we shall find it difficult to harmonize our general 
knowledge of morbid changes with the apparent exceptions that endo- 
cardial disease brings to our notice. 

A careful examination of the endocardium is necessary, before we 
determine positively that the appearances we find are due to pathological 
alterations; the earlier observations lose much of their value from post- 
mortem staining having been mistaken for inflammatory reddening. 
When the change of color, which naturally is of the palest white, and 
translucent, is due to inflammation, the redness cannot be washed off, 
nor is it rapidly destroyed by maceration; the membrane is pulpy and 
thickened, and in an advanced state, further products of inflammation 
are found beneath, or upon the membrane. Where the redness is the 
result of mere imbibition, we find the blood in the cavity fluid, and it 
occurs in cachectic individuals. The later the post-mortem examination 
is made after death, and the warmer the weather at the time, the more 
likely are we to find the lining membrane of the heart and arteries 
stained with blood. We rarely have an opportunity of seeing endocar- 
ditis in its first stage. Rokitansky and Hope describe inflammatory 
redness of the endocardium as mottled. Dr. Hope states it to be less 
characterized by streaks, patches, isolated unstained spots, and abrupt 
edges, than non-inflammatory imbibition. The discoloration is more 
perceptible in the arteries than in the cardiac cavity, owing to the sub- 
jacent tissue serving as a better foil in the former than in the latter. 
On the other hand, the next change, that of opacity of the lining mem- 



314 MORBID ANATOMY OF THE ENDOCARDIUM. 

brane, for the same reason shows more distinctly in the heart than in 
the arteries, where a transverse section will be required to demonstrate 
the increase of thickness. This alteration in the appearance of the 
endocardium also changes it in other respects ; it loses its glaze, and be- 
comes dull, relaxed, milky, and velvety. The redness of imbibition is 
darker in proportion to the period the blood is in contact with the pari- 
etes of a cavity, and for this reason it is observed, as pointed out by 
Hasse, 1 in the following descending order: darkest in the right auricle ; 
paler in the right ventricle, with the exception of the valves of the 
pulmonary artery, which are as deeply colored as the auricle ; still paler 
in the left auricle; whilst the left ventricle often retains quite its natural 
tint, except that the aortic valves are darker. In the great vessels, the 
posterior surface is strikingly dark, in comparison with the anterior. 

In rare cases, an adhesion has been found effected between opposite 
points of the parietes. When the inflammatory process extends to the 
valves, the consequent change in their relation to the blood-current, 
gives rise to those physical signs which are of so much value in the 
diagnosis of cardiac affection. The laxity of tissue induced by the in- 
flammatory process offers more or less impediment to the circulating 
fluid, and may even be the cause of a laceration of the cardiac lining, 
or of the extension of the membrane to the valves and arteries. 

The first effect of inflammation of the endocardium is the exudation 
of lymph on its free surface; where, however, it is rarely to be found, 
on account of the current washing it away; its absence was an argu- 
ment used by Laennec, against the assumption that the endocardium was 
liable to inflammation. In how far the fibrinous vegetations on the 
valves are the product of inflammation of the part, or a deposit of lymph 
exuded within the heart, or again, an elimination of fibrin directly from 
the blood, is a matter not absolutely decided. It appears to us that 
there is no difficulty in reconciling the conflicting opinions, by assuming 
that the valves may become the seat of these deposits, in each of the 
modes alluded to. We know that, if a thread be passed through a 
healthy artery, a coagulation of fibrin attaches itself to the foreign 
body; and we also know that inflammation increases the tendency to a 
separation of fibrin from the blood. There is, therefore, no necessity 
for the intervention of the coats of the capillaries to produce the effect 
of exudation, although the term certainly implies a transmission through 
a membranous expansion. We are satisfied that we have seen what is 
called exudation matter, within the small vessels of the pia mater, in 
meningitis, and, though the number of our observations are not sufficient 
to base any positive conclusions thereon, the fact may, quantum valet, 
aid in the present inquiry. Besides, the circumstance of the great 
tendency to valvular growths prevailing in rheumatic constitutions, 
supports the view of the frequent occurrence of deposits being effected 
directly from the blood. Rheumatism, more almost than any inflamma- 
tory condition, presents the character of a blood disease, and, consider- 
ing the preponderance of fibrin in the elements of the blood which 

1 An Anatomical Description of the Diseases of the Organs of Circulation, Syd. Soc. 
Ed. p. 128. 



MOEBID ANATOMY OF THE ENDOCAKDIUM. 315 

characterizes it, and the frequent complication with heart disease, it offers 
a further corroboration of the view just advocated. It is, in fact, the 
same as that expressed by Dr. Hope, when he says that the vegetations 
on the valves are caused by inflammation inducing either an effusion of 
coagulable lymph, or by its imparting to the blood in contact with the 
inflamed part, a morbid tendency to coagulate. 

If the discovery of lymph on the inner surface of the heart is an 
unusual circumstance, it follows a fortiori ', that we still less frequently 
meet with a purulent effusion resulting from endocarditis. Rokitansky 
remarks on the subject, that although the recognition of the seat and 
position of pure pus, as a free product, is, in most cases, impracticable, 
it is not difficult to prove the extreme probability of the existence of 
such a process. The loosening of the tissue, the want of polish, and 
the felt-like character of the endocardium, are very strongly marked in 
the centre of inflammation, and hence lacerations frequently occur. In 
these cases, a purulent product mixed with the blood is generally found 
infiltrated into the tissue, if not at the surface of the endocardium; whilst 
abscesses are occasionally found to have spread themselves over a vari- 
ous extent of surface below the endocardium, in the cellular and adjoin- 
ing muscular strata, deep in the tendons, and in the tissue of the valves. 

One of the effects of endocarditis is ulceration; it is met with on the 
parietes of the heart, but more frequently on the flaps of the valves, where 
it gives rise to perforation and rupture. Perforation of the septum ven- 
triculorum occasionally results from this cause. A free communication 
may thus be established, or the muscular wall may be completely de- 
stroyed ; but an exudation of fibrin having taken place on the distal side, 
the intermingling of the contents of the two cavities may be prevented. 
We find the two lesions associated, as for instance in Bouillaud's 1 sixty- 
sixth case ; the subject, a man aged thirty-seven, was seized with rheu- 
matism, upon which pericarditis and endocarditis supervened, causing 
death on the thirty- first day of his illness. At the cadaveric inspection, 
a cauliflower excrescence of fibrin was found upon the ventricular sur- 
face of one of the aortic semilunar valves ; upon which, besides a fringe 
of lymph along its free margin, two perforations were discovered, one 
at the middle of the flap, the other lower down, and communicating with 
a cavity in the muscular tissue large enough to contain a bean ; to the 
right of this flap there was a red spot of three lines in diameter, in the 
centre of which was a small circular ulcer, sufficiently large to admit the 
head of a pin. Bouillaud also gives two instances in which endocarditis 
was followed by gangrene, a conclusion, however, which some have cavilled 
at. The following is an abstract of the most satisfactory of the two : The 
patient, a robust individual, aged fifty-six, after exposure to a draught 
while much heated, was seized with endocarditis, and death ensued in six 
weeks. The post-mortem was made thirteen hours after death, and two 
of the aortic valves were found indurated at their base, and adherent to 
one another so as to interfere with the current. The endocardium 
covering their base was red, thickened, and presenting an abrupt red 
fringe, at a short distance from the free margin. The remainder of the 

1 Traite Clinique des Maladies du Coeur, yoI. ii. p. 29. 



316 MORBID ANATOMY OF THE ENDOCARDIUM. 

valve was ulcerated, soft, friable, of a dirty gray, and eroded ; one pre- 
sented a perforation. The two flaps, says M. Bouillaud, 1 closely re- 
sembled the appearance of gangrene of the cutaneous surface, with a 
red line of demarcation. Dr. Copland, as we have already seen, is of 
opinion that gangrene will only supervene when internal carditis attacks 
a cachectic habit of body, or when there is a septic tendency induced in 
the system, by a depraved state of the circulating fluids, or by impaired 
vital power. 

A frequent concomitant of endocarditis, appears to be, according to 
the statistics of Bouillaud, who has met with a larger number of fatal 
cases of endocarditis than any English physician, the coagulation, dur- 
ing life, of the blood, and the organization, in the clot, of new blood- 
vessels ; the coagulum is found adherent to the parietes of the cavity, 
and requires some force for its removal. It is colorless, elastic, and 
glutinous, and closely resembles the bufty coat of inflammation, or false 
membranes themselves. The symptom by which Bouillaud recognizes 
this occurence before death, is, a want of accordance between the pulse 
and the heart in point of force ; the heart presenting evidence of violent 
excitement and action, while the pulse is small and evanescent. Gluge 2 
describes organized fibrinous coagula under the name of hsematoma, and 
gives an interesting instance, with the minute anatomy of the clot, which 
occurred in a female, aged fifty-two. The left auricle was filled with 
a red tumor, surrounded by a delicate membrane, in the interior of which 
he distinctly traced capillary vessels, forming a retiform plexus. Simi- 
lar instances may be also found in the records of the Pathological Society, 
and in Dr. Hodgkin's Catalogue of Gcuys Hospital Museum. The cases 
in which organized clots or fibrinous coagula have been found by English 
observers, were generally connected with a cachectic condition, analo- 
gous to what Bokitansky terms the fibrinous crasis. The surface is 
found more or less intimately connected with the endocardium, while 
the interior of the clot may, in its turn, be undergoing further changes 
of an inflammatory or degenerative character. The fibrin is seen to 
be breaking up into a granular condition ; exudation or inflammation 
corpuscles and fibro-plastic cells may be exhibited by the microscope. 
This does not necessarily apply to the pus that is occasionally found 
within the coagulum, which is to be regarded rather as the cause than 
the consequence of the coagulation. The pus may be derived from 
various sources ; Cruveilhier 3 observes that it may be generated at a 
distance, and be carried to the heart by the blood-current ; that it may 
be the result of inflammation occurring in the coagulum, or that it may 
be the product of endocarditis ; in which case it is absorbed into the 
coagulum, by capillary attraction. Tuberculous concretions have also 
been found in the clot ; however they gain the position, it must be before 
death ; changes affording sufficient proof of the independent vitality of 
the concretion. The older pathologists attributed a much greater im- 
portance to fibrinous coagula, or, as they termed, them, polypi, in the 

1 Traits Clinique des Maladies du Coeur, vol. ii. p. 87, Observ. 87e, 

2 Atlas der Pathologischen Anatomie, Lieferung 11, 
a Anat. Pathol, livr. 25. 



MORBID ANATOMY OF THE ENDOCARDIUM. 317 

heart, than they now obtain, owing to their being regarded as the im- 
mediate cause of death. It is only in rare cases that we shall be justi- 
fied in looking upon them as products formed during life; in the majority 
of instances they are merely the first evidence of the arrest of vitality, 
and the incipient influences of the metamorphoses of decay. When formed 
during the agony, or after death, there is no adhesion to the parietes ; the 
polypus is moulded to the cavity which contains it, and a straw-colored 
fibrinous layer invests a blood-clot, similiar to the buffy coat covering the 
coagulum of blood obtained by venesection. The view we have taken of 
the organized polypi is supported by Hasse, 1 who observes that the seat 
of morbid action giving rise to them is, in the majority of instances, 
remote from the heart. Under certain circumstances the blood retained 
after the systole in the ventricles, and impelled into the network of the 
columnae carneee, acquires the opportunity to coagulate ; and one fixed 
point being given, it is easy to understand how constantly fresh deposits 
are made on the surface, causing a laminated appearance, and aiding 
in the process of organization. 

A second form of fibrinous concretion is described by Rokitansky, 
under the name of globular vegetations, as round masses, varying from 
the size of a pin's head to that of a nut, attached by means of rami- 
fying cylindrical or flat appendages or bands, which entwine themselves 
among the trabecule of the heart, and are of a more or less uniformly 
dirty grayish-red or white color. He states them to be hollow in the 
interior, and to contain, within a wall of irregular thickness, a dirty 
grayish-red or even chocolate-colored fluid, resembling cream or pus. 
One or more of these concretions very frequently burst, when the fluid 
may be seen effused into the cavity of the heart, and distributed over 
the recent coagula, which have been formed either in the death-struggle 
or shortly after death. 

Rokitansky establishes a third concretion, under which he comprises 
all vegetations of the valves of the heart, presenting a shaggy appear- 
ance, resembling villi, forming shaggy pedicled excrescences, or offering 
a cock's-comb or mulberry-like appearance. They affect the free mar- 
gins of the valves, the tendons of the papillary muscles, and also attach 
themselves to the endocardium. They float in the blood, and necessarily 
lie in the direction of the current. 

It appears that we have sufficient evidence to believe that they may 
occasionally become detached and be carried by the force of the circu- 
lation as far as the first angle of a vessel offering an impediment, or 
until they reach a channel which is too small to permit of their trans- 
mission. Dr. Kirkes, 2 in an interesting paper presented to the Medico- 
Chirurgical Society, has carefully investigated the circumstance, and 
recorded several instances in illustration. The part more immediately 
affected depends, according to this author, in the first instance, upon the 
circumstance of the fibrin being detached from the right or the left side 

1 An Anatomical Description of the Diseases of the Organs of Circulation and Respira- 
tion, Syd. Soc. Ed. p. 127. 

2 Medico-Chirurgical Transactions, vol. xxxv. p. 281. 



31.8 MORBID ANATOMY OF THE ENDOCARDIUM. 

of the heart. In the former case, the pulmonary, in the latter, the sys- 
temic circulation will become affected. When the mass of fibrin is 
detached from the left side, the lodgement is most commonly effected in 
one of the middle cerebral arteries, a circumstance explicable by the 
anatomical relation of these vessels. The arteries of the spleen and 
kidneys appear to be liable, next in order, to similar deposits, on 
account of their receiving their arterial supply by large vessels directly 
from the heart. That the plugging up of an artery must induce a change 
of nutrition in the part to which it leads, scarcely requires to be dwelt 
upon; while it causes coagulation of the blood behind, it acts as a 
foreign body, exciting inflammation and exudation, or degenerative pro- 
cesses, as softening and gangrene. In how far such an occurrence is 
remediable is very doubtful, though Dr. Kirkes suggests that a breaking 
up and absorption may take place, or that, by a dilatation of the blood- 
vessel, the current may be enabled to pass it ; in the latter case, we 
should imagine it more probable that the plug would be propelled, espe- 
cially as one characteristic of this variety of deposit is that it enters 
into no close adhesions to the inner coat of the vessels. Twenty-one 
cases have been analyzed by Dr. Kirkes, in which these deposits were 
found, and in every one but two he found disease of the valves and of 
the interior of the heart. One of these was a case of cholera, in which 
a doubtful mass of capillary phlebitis existed in the liver; the other was 
a case of aneurism of the aorta, which the author looks upon rather as 
favoring his views. In fourteen out of the remaining nineteen, fibrinous 
growths were noted on the surface of the left valves, or the interior of 
the left cavity. 

Note. — Since the above has been in type, we have seen that Dr. Todd is not inclined to 
adopt Dr. Kirkes's view, but would refer the coagulum found in the distant artery to an 
altered nutrition of its wall — to arteritis — and connected with a rheumatic or other morbid 
state of the blood. [Clinical Lectures on Paralysis, &c, 1854, p. 176.) 



CHAPTER XXI. 

DISEASES OF THE VALVES OF THE HEART. 

The estimates of different authors, with regard to the influence 
exerted by inflammation in producing valvular disease, have varied con- 
siderably. Bouillaud attributes nearly all changes occurring in the 
valves, such as altered consistency and form, fibrinous concretions, cal- 
careous and ossific deposits, to inflammatory action, terming them the 
third stage of the inflammatory process ; while Rokitansky, and many 
with him, are of opinion that they are only in part the product of endo- 
carditis, but that the majority are the result of slow changes of nutrition, 
not connected with inflammatory action. 

The most manifest direct results of endocarditis are white opacity and 
thickening of the endocardium and the lining membrane of the valves, 
and adhesion between the latter. Adhesions are most commonly found 
in the aortic valves, and this lesion must necessarily constitute a perma- 
nent and very serious obstacle to the circulation, in its turn giving rise 
to further disorganization and derangement, such as hypertrophy and 
dilatation, asthma and anasarca. In dealing with this species of mal- 
formation, it is often very difficult to determine whether it is congenital 
or the result of disease, especially when, subsequent to adhesion, an 
absorption of the partition separating the two pouches is effected, and 
the double valve thus converted into one. Dr. Peacock 1 has analyzed 
fifty cases of malformations of the pulmonary and aortic semilunar 
valves, among which he found forty-one of defective, and nine of ex- 
cessive development. Of the former, nine were found at the pulmonic, 
and thirty-two in the aortic orifice. The varieties which the fusion of 
the valves with one another, or their adhesion to the walls of the heart, 
may present, are very numerous. In all cases an insufficiency of the 
valves must result, which both offers an obstacle to the free discharge of 
the blood from the heart, and fails adequately to close the orifice during 
the diastole, so as to prevent regurgitation. The left side of the heart 
generally, and especially in regard to inflammation, offers by far the 
greatest proclivity to disease. Very few cases are recorded in which a 
phlogistic process could be demonstrated on the right side. Gluge 2 
gives two observations in which the tricuspid valve was thickened and 
rendered insufficient by this cause. We also find two instances reported 
in Dr. Hodgkin's Catalogue of the Museum of G-uy's Hospital (Nos. 
1401 and 1402), in which the curtains of the tricuspid were thickened. 

1 Reports of the Pathological Society, 1851-52, p. 292. 

2 Atlas der Pathologischen Anatomie, 1850, Lieferung i. Beobachtung, 12 and 12a. 



320 



DISEASES OF THE VALVES OF THE HEART. 



In one of these there was also shortening of the tendinous cords. While 
the arterial valves are more subject to this species of lesion, we find the 
mitral valve more prone to an hypertrophy of its fibrous tissue, which 
is especially liable to present itself in the shape of nodulated masses, 

Fig. 141. 




Fibroid thickening of the mitral valve. 

fringing the curtain, and in some instances closely resembling accumu- 
lations of fat. The microscope at once determines their real nature, as 
it exhibits, instead of fat-cells, a fibroid structure, containing nuclei and 
elongated nucleated cells. In connection with hypertrophy of the endo- 
cardium, we find the lining membrane of the valves also thickened; by 
which means it appears that, independently of inflammatory action, a 
secondary adhesion may be effected between the flaps. Here the aortic 
valves are more liable, though it is not at all unusual to find the curtains 
of the left auriculo- ventricular orifice opaque throughout, from the same 
cause. 

We have already alluded to perforation of the valves, as a result of 

Fig. 142. 





Fibroid thickening of a pulmonary valve, extending symmetrically on both sides of the curtain, and con- 
sisting of a soft fibrillating deposit. It was found in a man who had a broken spine. 



endocarditis. Another form in which the same lesion occurs is in con- 
nection with atrophy. This is manifested, in the first instance, by 



DISEASES OF THE VALVES OF THE HEART. 321 

attenuation, and increased transparency of the valves ; as this advances, 
one or more openings are effected, which may be sufficiently numerous 
to induce a cribriform appearance. It is only when the perforations are 
large or numerous that they interfere, to any serious extent, with the 
circulation. Thus, in the case of a man who died recently at St. Mary's 
Hospital, after an operation for popliteal aneurism, the cause of death 
being extensive pneumonia, there was much fibrinous deposit on the 
aortic valves, with two valve-like perforations, apparently the result of 
ulceration, which had given rise to murmurs of a peculiar character 
before death, but not, apparently, inducing any other symptoms of 
cardiac disease. Dr. Kingston, 1 who was the first to draw attention to 
this point, observes, that atrophy may be defined a simple shortening 
of the valve, and, in the first instance, a mere atrophy in the direction 
of the length. He speaks of the cribriform appearance in the flaps as 
also resulting from the same process, and has found the two conditions 
chiefly in the mitral and tricuspid valves. In this, he differs from other 
authors. Rokitansky, for instance, has only met with the lesion in the 
arterial valves. Dr. Kingston, out of about thirty cases of valvular 
disease, found the lesion to be atrophy in ten. The mitral valve was 
shortened in five, the tricuspid in five ; both in two. In one the mitral 
valve was cribriform, in two the tricuspid, and in one both the aortic 
and pulmonary valves were so. 

The lesions of the valves hitherto spoken of may be variously com- 
plicated with one another, or with heterologous growths. Pathological 
records contain instances of a great variety of changes of form, the 
result of morbid processes or accident. Thus, the individual flap of the 
semilunar valve may be reverted or inverted, 
the valves of the aorta may become detached at 
their bases, and thus lose the fulcrum by which 
they resist the impetus of the blood, or the 
tendinous cords of the mitral may induce a 
deficiency of the valve by a shortening and 
thickening, a lesion which Dr. Hope considers 
as constituting one of the worst varieties of 
disease of the valves. 

Among the anomalies of consistence, Roki- 
tansky describes, besides the increased density 
of thickened and shrivelled valves, and the 
softening that results from inflammation, a Aortic valves of a child aged four 

, . ° ,.. „. .. i • ■ i i i years ; they are opaque and thick- 

gelatinOUS Condition 01 the Valve Which he has ened, and their free margin curled 

found in the Valves Of the left Side Of the backward towards the artery. Two 

heart exclusively. There is a loSS Of fibrOUS of the valves are closely united by 

„ l ■ i i 11 their adjacent margins. — St. Bar- 

tlSSUe, tor _ Which a gelatinOUS, non-adhesive tholomew's Museum, llth Series. 

substance is substituted, causing the valve 52. 

throughout, or only in parts, to become soft 

and pliable while its color is converted into a pale yellow or reddish hue. 

The author is of opinion that there is no effusion of new matter, but 

that the gelatinous substance is merely the disintegrated fibrous tissue 

1 Medico-Chirurg. Trans., vol. xx. p. 90. 

21 




322 



DISEASES OF THE VALVES OF THE HEART. 



of the valve itself. It appears that while on the one hand this condi- 
tion may lead to lacerations, especially of the valves of the aorta, pre- 

Fig. 144. 




Atheromatous deposit in the valves of the aorta of a man aged 26. -with rupture at the point marked by 
* ; there was also congenital union at the point (marked by f ) of two of the valves. The case is described 
in the Reports of the Pathological Society, vol. iv. p. 100. 

senting the fissured appearance of true rents, to distinguish them from 
the perforations resulting from atrophy, it is also susceptible of cure by 
a reconversion into fibrous tissue. 

Fibrous and ossific deposits, which we have seen to be not uncommon 
on the surface of the heart, are very rarely met with under the endo- 
cardium except in connection with the valves. To the former, which are 
often rather hypertrophied states of the normal fibrous tissue, we must 
attribute many of the lesions already adverted to, consisting of malpo- 
sition, eversion, and inversion, of the valves ; the fibrocartilaginous and 

Fig. 145. 




Aortic valves of a man set. 47, rendered perfectly rigid by calcareous deposit. The patient was affected with 
granular kidneys and cirrhosis of the lrver. 

cartilaginous induration spoken of by Bouillaud and others, may be 
referred to this head. The calcareous or ossific deposit is a distinct new 
formation. It presents the most varied forms, which may be compared 
to the fantastic shapes assumed by molten lead when poured into water; 
sometimes resembling stalactitic projections, at others forming irregular 
rounded eminences, stretching across the orifices of the heart like rigid 



DISEASES OF THE VALVES OF THE HEART. 



323 



bars, maintaining the valves in a state of permanent erection or disten- 
sion, and inducing symptoms both of obstruction and of regurgitation. 
A single flap or curtain may be rendered rigid while the others retain 
their natural pliability : the valves of one side of the heart may be more 
or less intimately united by the morbid growth ; but whatever forms 
the lesion may assume, it is scarcely possible to occur without a perma- 
nent narrowing of the orifice. Kreissig and Bouillaud refer the disease 
uniformly to inflammatory action ; and Dr. Watson is also of opinion 
that it is somehow certainly connected with inflammation of the internal 
lining of the heart. But we must not overlook the important fact of 
the natural tendency existing in the arterial system generally, as well 
as in other tissues of the body, to induration and ossification with ad- 
vancing life; and though we are far from looking upon ossification of 
the valves as a physiological process, we are justified by analogy, as 
well as by the positive fact of the very chronic nature of these deposits, 
in looking upon them in many cases as of a non-inflammatory character 
allied to the general species of degenerative disease. Lobstein's view, 
that these concretions are intimately allied to the gouty diathesis^ is one 
that must not be lost sight of ; though he perhaps erred in restricting 
them too closely to this particular constitution. Although we have used 
the term ossification in accordance with common usage, to designate the 
change under consideration, it is important not to confound the process 
with the one in which genuine bone is formed : cretification or calcareous 
deposition would be a more appropriate term, for there is no resem- 

Fig. 146. 





Ossification of the aortic valves; a thick calcareous deposit has taken place between the valvular niem- 

hranes, interposing a rigid and almost imperforate diaphragm between the cavity of the heart and the 

vessel. 

A. Upper surface, b. Under surface. 

From St. George's Hospital Museum, E 18. 



blance between the morbid product and true bone. It consists essentially 
of carbonate and phosphate of lime deposited in irregular, amorphous 
nodules, and resembling more a chemical precipitation than an organic 
formation. The material is more or less friable, and is connected by 
the remains of the fibroid, or atheromatous matter, in which it formed. 
It is soluble in the mineral acids. It is often difficult, when we meet 
with an advanced case, to determine in what part the deposit first takes 
place ; whether beneath or on the surface of the lining membrane. The 
opinions of different writers differ with regard to this question. The 
most common form undoubtedly is the conversion of atheromatous or 
fibroid deposit underneath the lining membrane analogous to what we 



32-4 DISEASES OF THE VALVES OF THE HEAET. 

see occurring in the arteries ; and as this enlarges, the membrane be- 
comes softened and destroyed, and the ossification then projects free 
into the sanguineous current. It is not the mere increase of the deposit 
which determines this solution, but an element in producing this result 
is undoubtedly a morbid affection of the lining membrane itself, in which, 
even in early stages of degeneration of the subjacent tissue, we have 
observed disintegrating processes, of which we shall speak further when 
discussing the diseased conditions of the arterial system. One of the 
most extreme cases of narrowing of the aortic orifice in an adult, that 
we have met with, is the one delineated (Fig. 146), in which the continuity 
of the lining membrane was preserved entire over the ossific deposit. 
The passage was contracted to the size of a pea. 

Rokitansky is of opinion that we may establish three varieties of con- 
cretions: the first is similar to the form just described, but he terms it 
exclusively ossification of the fibroid tissue developed in the interior of 
the valve by inflammation ; he calls the second form, ossification of 
endocardial deposit, on the surface of the valve; and he describes the 
third as an osseous concretion in a stalactitic form, or as a rough calca- 
reous agglomeration, which constitutes a metamorphosis of the vegeta- 
tions on the valve. These stalactitic osseous masses, he says, occasion 
and promote the continued formation of new vegetations; and are con- 
sequently very commonly surrounded by them. Calcareous concretions 
and morbid affections of the valves generally follow the law which de- 
termines the great prevalence of disease on the left side of the heart as 
compared with the right side : ossification, especially, is so rare on the 
right side that it has been denied altogether. Hasse, however, has seen 
partial ossification of the pulmonary artery; and Dr. Hodgkins 1 also 
reports a case of thickening and bony deposit in the pulmonary artery 
close to the valves. 

A condition of the valves remains to be pointed out, which was first 
demonstrated by Dr. Thurnam; 2 it consists in a saccular dilatation, 
which he attributes to a gradual distension, and hence terms aneurism 
of the valves. It is met with in the aortic and tricuspid, but most 
commonly in the mitral valves. Dr. Peacock 3 has also recorded a simi- 
lar affection of the valve of the foramen ovale. We find that the dila- 
tation may exist without any lesion of continuity in the tissue ; the 
endocardial lining being traceable throughout the pouch. This, in the 
case of the mitral valve, projects into the left auricle, and is often filled 
with a clot of blood. This form would correspond with what is termed 
true aneurism of the arteries. A second variety is that resulting from 
inflammation of the valves, by which a solution of continuity is effected 
in the lining membrane. Rokitansky states that he has found it occur 
either as a fissure brought on by softening of the membrane, or by dis- 
integration of the subjacent tissue ; or again, by ulceration of the endo- 
cardium resulting from an abscess proceeding from the lowest part of 
the valve. Thus, he continues, when the valve has been perforated to 

1 Catalogue of Guy's Hospital Museum. No. 1403. 

2 Medico-Chirurgical Transactions, vol. xix. p. 162, vol. xxi. p. 187, vol. xxiii. p. 323. 

3 Pathological Reports, 1850-51, p. 80. Several instances of valvular aneurism are 
detailed in the same volume, pp. 72, 77, and 78. 



DISEASES OF THE VALVES OF THE HEART. 325 

a greater or less extent, the blood which impinges on it penetrates into 
its parenchyma and causes more or less extensive infiltration. We give 
this explanation in deference to the authority from whom it emanates; 

Fig. 147. 




Aneurism of the mitral valve; a pouch projecting into the cavity of the left auricle about three-quarters 
of an inch high, and half an inch wide. It has burst by an irregular rent on one side. St. Bartholomew's 
Museum, 12th Series, 62. 

we cannot, however, deny that the evidence in favor of the prevailing 
cause of valvular aneurism being dilatation of the coats, rather than a 
rupture of the membrane, appears to us to be the stronger. The form 
of the aneurism is almost invariably that of a circular cup, varying in 
size from a pea to a walnut ; nor does it appear from the cases which 
we have analyzed, that the affection so uniformly terminates in lacera- 
tion as Rokitansky affirms. 

We have for the sake of convenience reviewed the diseases affecting 
the individual tissues of the heart separately; but before proceeding 
further, it may be well to dwell for a brief space upon their complica- 
tions with one another, and with morbid phenomena in other vital 
organs. The fact of the intimate connection between a rheumatic dia- 
thesis and pericardial and endocardial inflammation, has already been 
alluded to. We cannot show the relation better than by extracting 
from Dr. Latham's Lectures on Clinical Medicine, the statistical facts 
illustrative of the subject, to which that author's large experience had 
led : The number of cases of acute rheumatism which occurred to him 
were 136, out of which 90 presented symptoms of heart disease ; of 
these 63 were diagnosed as affecting the endocardium alone, 7 the peri- 
cardium alone, and 11 both endo and pericardium. Out of the total 
number only three proved fatal; they were men, and in them both sur- 
faces of the heart were inflamed. In all cases of heart disease other 
organs will be liable to be affected in proportion, as different parts of 
the circulation are more immediately involved. While disorders of the 
arterial system more directly induce deranged action in the brain, the 
spleen, and the kidneys; the lungs, the liver, and the chylopoietic 
viscera suffer chiefly in derangements acting immediately upon the 
venous system. As a matter of course this distinction is one that can- 
not be always demonstrated, as in an advanced stage of cardiac disease 
of either side of the heart, or of any one portion, the entire circulation 
must of necessity be impaired. On the arterial side we find that more 
particularly a complication between granular degeneration of the kid- 



326 CYANOSIS. 

neys with heart disease ohtains; thus, Dr. Bright has shown that in a 
hundred cases of this disease, the heart presented lesions in at least 
thirty-five, a number which would probably have been increased if the 
condition of this organ had been noted with the same care in all. This 
proportion has been confirmed by the researches of Dr. Taylor. 1 The 
secondary effects produced by the dislocation of lymph from the left 
side of the heart, in the brain, the spleen, and the kidneys, by blocking 
up the arteries, and thus altering the nutrition of the parts to which 
they lead, we have already alluded to. The influence of valvular dis- 
ease in producing hypertrophy is a point of great importance, and its 
connection with pericardial and endocardial inflammation has been 
especially dwelt upon by Bouillaud. Its influence in affecting the cir- 
culation in the brain is undeniable, but it is probable that the frequency 
with which it induces hemorrhage, either in the lungs or in the brain, 
has been overrated. In many of the cases on record of cerebral apo- 
plexy connected with cardiac hypertrophy, the result was more justly 
attributable to the coincident arterial disease than to the increased 
impulse of an enlarged heart. Pulmonary apoplexy appears rather to 
be connected with the obstructions to its circulation presented by mitral 
disease than by an hypertrophic condition of the heart. With regard 
to the liver, we find that in fatty degeneration of the heart it commonly 
presents a similar concomitant affection, not to speak of the congestion 
to which it is almost invariably subject when the return of the blood to 
the heart is in any way impeded; more than any other organ it is 
enabled by its size and elasticity, as well as by its functions, to serve 
as a species of reservoir where the balance of the circulation is dis- 
turbed, a reservoir which may be frequently overcharged, but from 
which we are more able to draw off the surplus without too much debi- 
litating the system than from any other organ. Congestions of the 
venous system of the entire body are frequent in cardiac disease, and 
manifest themselves by lividity of the cutaneous surface and of the 
mucous membranes : and the secondary effects of stasis are shown in 
these tissues by oedema and hemorrhage, while in the serous cavities 
they are evidenced by an effusion of serum — one form of passive dropsy. 
Of the latter, we find the peritoneum chiefly prone to suffer, a circum- 
stance which we may fairly attribute to the absence of any compression, 
such as we find normally exerted upon all the other serous sacs. With 
these few remarks on a subject which belongs rather to the domain of 
the history of disease than the records of morbid anatomy, we pass to 
the consideration of the conditions with which cyanosis is found asso- 
ciated. 

CYANOSIS. 

Cyanosis is a term applied to a livid, purplish hue of the cutaneous 
surface, which is found to accompany some organic and congenital dis- 
turbances in the central organ of the circulation, of a more intense 
character than the slaty tinge which the complexion is very frequently 

1 Medico-Chirurg. Trans., vol. xxviii. p. 536. 



CYANOSIS. 327 

observed to assume in acquired disease of the heart. It was formerly 
attributed, on theoretical grounds, solely to one lesion, a permanent 
patency of the foramen ovale ; and although this occasionally gives rise 
to the affection, by allowing an intermixture between the blood of the 
two sides of the organ, and causing it to be circulated through the sys- 
tem, without having undergone the purifying process to which it ought 
to be subjected in the lungs; it is satisfactorily demonstrated, both that 
the foramen ovale may remain open, to a considerable degree, through- 
out life, without inducing any serious disturbance of the circulation ; 
and on the other hand, that various other irregularities in the heart 
may give rise to cyanosis. Bizot found the foramen ovale more or less 
open in forty-four out of 155 subjects, in none of whom there was a 
trace of the morbus coeruleus. Two openings have been found in the 
ventricular septum, and no cyanosis resulted ; a marked instance of this 
kind in an individual who attained to the age of eight years, was brought 
before the Pathological Society, by Dr. Quain, in 1847. In such a case, 
we are justified in assuming that the forces of the two sides of the heart 
are so exactly balanced as not to disturb the circulation ; and the orifice 
of the pulmonary and systemic arteries being patent, the contents of 
each side pass into their proper channel. That this is a prevailing law 
for many cases of cyanosis, is shown by the fact that it frequently does 
not manifest itself unless there is some further cause for derangement of 
the circulation, such as a bronchitic affection, to which, it may be re- 
marked, cyanotic individuals are peculiarly subject. 

The lesion that appears to be most constantly associated with cyanosis, 
and which may be regarded as its primary cause, is a contracted state 
of the pulmonary artery ; and, as in that case more than usual pressure 
will continue to be exerted upon the foramen ovale, this will necessarily 
remain patulous, and allow a passage of blood from the right to the left 
auricle ; in such a case it may be almost looked upon as a safety valve. 
Gintrac 1 has analyzed fifty cases of cyanosis, and among them found 
obstruction at the pulmonic orifice in twenty-six; the proportion is stated 
to be still greater by other authors. But the blue disease is not neces- 
sarily the result of an admixture of the contents of the two sides of the 
heart ; anything causing an arrest in the return of the venous blood to 
the heart is sufficient to give rise to it. In the first volume of the 
Pathological Reports (1847, p. 25), we find a case of marked cyanosis, 
recorded by Mr. Ebenezer Smith, in which the foramen ovale was per- 
fectly closed, and had evidently been so for some time before birth ; 
there was no inter-ventricular communication, the pulmonary artery was 
large, but the left auriculo-ventricular opening was small, and the left 
ventricle was almost obliterated; the walls were contracted on a small 
cavity at the base, not exceeding two or three lines in diameter. The 
aortic opening was also very small, being about two lines wide ; and the 
arch was much smaller than the pulmonary artery. The mitral valve 
was altogether defective in structure, consisting only of two small bands 
without any curtains. Here, then, there was an evident arrest at the 
aortic orifice, which reacted upon the pulmonary circulation, and through 

1 Sur la Cyanose, Paris, 1824. 



328 CYANOSIS. 

that upon the systemic capillaries. The lungs were too much charged 
with blood to perform the duty of aeration effectually, and a congested 
or cyanotic condition of the surface resulted. Similar instances of the 
cyanosis being due to contraction at the aortic orifices are on record, 
but it may also happen without this symptom. Dr. G. A. Rees pre- 
sented the heart of a child to the Pathological Society, in 1847, 1 in 
which the aortic was much smaller than the pulmonic orifice, and there 
was no cyanosis. The ductus arteriosus continuing open, allowed the 
blood to pass from the pulmonic artery, directly to the aorta, so that the 
blood distributed to the lower part of the body must have been almost 
entirely venous. 

One of the most palpable instances that has occurred to us, proving 
how little we are able to account for cyanosis theoretically, was that of 
a child that lived to the age of nine weeks, and whose heart, after 
death, was found to present no auriculo-ventricular opening, on the 
right side, while there was scarcely any inter-ventricular septum at all. 
Here there had been no cyanosis, although a thorough intermixture of 
the venous and arterial blood must have necessarily taken place. 

Bouillaud 2 is of opinion that the communication between the two sides 
of the heart, and the consequent admixture of the arterial and venous 
blood, has, comparatively, little to do with the purple hue of the com- 
plexion, which he considers to result, mainly, from the coincident obstacle 
offered to the circulation by a malformation of the arterial orifices of the 
heart. The numerous cases on record, in which not only the foramen 
ovale was patulous, but in which there was further evidence of the actual 
passage of the blood, directly from one side of the heart to the other, 
shows, as Dr. Peacock 3 has remarked, that there is a want of just rela- 
tion between the amount of venous blood entering the general circulation 
and the degree of cyanosis. The lesions that are found in connection 
with this symptom, consequently, require to be carefully analyzed, 
before we can determine the exact part that each bears in its produc- 
tion. They may shortly be enumerated as a patulous condition of the 
foramen ovale, from the valve not entirely covering the orifice ; with this 
a defective involution of the Eustachian valve is commonly combined ; 
permanent patency of the ductus arteriosus ; contraction of the arterial 
orifices ; a deficiency in the intra-ventricular septum ; and the malfor- 
mation in which the aorta springs from both ventricles. The effect upon 
the heart itself in these cases is to produce hypertrophy and dilatation, 
more especially of the right ventricle. 

Cyanosis is a disease which generally shows itself at or immediately 
after birth. The circumstance that it occasionally makes its appearance 
later in life, has induced Meckel and Abernethy to assume that the 
foramen ovale may reopen, an hypothesis which is unnecessary, as we 
now know how frequently a communication exists between the auricles, 
without producing cyanosis, and that this lesion may, under certain cir- 
cumstances, as in diseased states of the lungs, induce a disturbance in 

• Reports, 1847-48, p. 203. 

2 Traits Clinique, &c. vol. ii. 690, seq. 

3 Pathol. Reports, 1848, p. 202. 



CYANOSIS. 329 

the balance of the circulation, sufficient to force the blood through the 
auricular septum. 

Stress has been laid by several authors upon the circumstance that 
the fingers of cyanotic individuals are found clubbed. We only advert 
to it, to mention that it is by no means diagnostic of this form of heart- 
disease, or, in fact, of any distinct malady. A more important point, 
is an observation that Rokitansky concludes his remarks on the subject 
with; to the effect that cyanosis is incompatible with tuberculosis, against 
which he states that it offers a complete protection. We do not deny 
that this is the prevailing rule, yet it is not as absolute as the author 
quoted asserts. In the Report of the Pathological Society for 1848 
(p. 200), we find a case presented by Dr. Peacock, which refutes the 
universality of the law. There the post-mortem examination of the 
individual, a young man, aged twenty, established the following facts : 
The right lung was extensively permeated by tubercle, and towards the 
apex exhibited several small cavities; the left lung contained much solid 
tubercle; the heart was hypertrophic; the pulmonary artery exhibited 
a complete diaphragm, formed by adhesion of the valves, leaving only a 
small triangular aperture ; the foramen ovale was very widely patulous. 
There had been cyanosis during life, but not in a very marked degree. 

Besides the malformations of which we have just spoken, we find other 
congenital affections of the central organ of the circulation which are 
compatible with life, to which we must briefly turn our attention. Those 
hitherto mentioned have all been instances of an arrest of development; 
an excess of development is rarely met with in the heart, except as an 
acquired condition. In all the varieties of congenital arrest, we see a 
tendency to return to the primitive type of a single pulsating cavity; in 
itself a sufficient proof, if any be needed, that the organ is not a com- 
bination of two originally distinct hearts, but that it arrives at its perfect 
state by a subdivision of a single cavity. As the growth proceeds through 
its different stages, from the simplest condition of the pulsating vessel, 
to the complex mechanism of the perfect heart, we see close resemblances 
between temporary conditions of the human heart, to permanent condi- 
tions of the heart in the lower animals. Thus, the type of the piscine 
heart is presented in those cases where, in a man, we only find a single 
auricle and ventricle. Here, an aorta proceeds from the latter, from 
which the lungs are nourished by the ductus arteriosus, while both venae 
cavse and pulmonary veins discharge into the auricle. Children are 
known to live several months with this defect, without necessarily pre- 
senting any marked symptoms of deranged circulation. In the next 
degree, we find an analogy with the amphibious heart, the septum ven- 
triculorum being absent, or imperfectly developed, while there are two 
auricular cavities. A defect in the ventricular septum is commonly 
associated with that malformation of the aorta, in which it communicates 
with either side of the heart, the pulmonary artery being displaced, or 
altogether absent. The defect in the inter-ventricular septum may 
present various degrees, from a mere rudiment at the apex, to a full 
development of the partition, with the exception of a minute orifice near 
the base. 

A very curious anomaly, a genuine freak of nature, consists in a 



330 CYANOSIS. 

transposition of the pulmonary artery and the aorta, the former arising 
from the right, the latter from the left ventricle; an accident which is 
attributable to an abnormal division being effected in the arterial bulb, 
at the period of intra-uterine life, when the branchial arches are being 
converted into the arteries of the upper extremities and head, and into 
the pulmonary arteries. Again, we are informed by Tommasini 1 of an 
instance occurring in a female, aged twenty-five, who had not been 
cyanotic until the last days of her life, and had enjoyed general good 
health, in whom a circular orifice in the parietes of the left ventricle, 
established a permanent and free communication between this cavity and 
the pulmonary artery. Other varieties, in the configuration of the heart 
and the distribution of the vessels, are recorded in the works of Meckel 
and Geoffroy St. Hilaire, which contain a full account of everything 
relating to the subject. We have adverted to those most frequently met 
with. The valves of the heart, in these various malformations, generally 
present some alteration, being thickened, corrugated, or otherwise 
changed from their normal constitution. An alteration in the caliber 
and form of the parietes of the heart is not less frequently found to 
accompany the arrest of development spoken of; hypertrophy of one or 
more parts is a very common accompaniment. The valves frequently 
present a congenital arrest, or excess of development, sometimes inde- 
pendent of any other malformation of the heart, but commonly associated 
with further lesions. In reference to the arterial orifices, Dr. Peacock 2 
observes that the aperture may be defended by a single valve, protruded 
forwards in the course of the circulation, a condition seen chiefly in the 
pulmonic artery, or only two valves appear, owing to two having united 
at their edges; or again, there may be two fully developed semilunar 
valves, with an abortive valve intervening. Of forty-one cases of defect 
in the number of the valves, Dr. Peacock found the malformation at the 
pulmonic, in nine ; in thirty-two, at the aortic orifice. Of fifty cases of 
malformation of the semilunar valves examined by the same observer, 
nine were examples of excessive development. Of these, he found that 
eight were cases in which the pulmonic valves were in excess, and in 
one only was there more than the natural number of valves at the aortic 
orifice. " In some cases, the excess in the number of valves seems to be 
due to the division of one of them into two, such divided valves being 
smaller in size than the others. In others, there are three valves of 
nearly equal size, with a smaller supplementary valve interposed between 
two of them. Occasionally, the aperture is provided with four valves, 
gradually decreasing in size, and in the other cases there may be four 
valves of nearly equal size, and natural form." Similar defects are met 
with in the tricuspid and mitral valve, but more rarely. 

1 Quoted by Bouillaud, vol. ii. p. 674, 1841. 

2 Report of the Pathol. Soc, 1852, p. 292. 



CHAPTER XXII. 

THE BLOODVESSELS. 

In estimating the morbid lesions occurring in the bloodvessels, we 
must bear in mind that they are mere conduits for the fluid, by which 
nutrition and the metamorphoses of the tissues are effected, and that 
they therefore bear a very different relation to disease from that pre- 
sented by the central organ of the circulation, or by the blood itself. 
It is the more necessary to urge this, as so much that has been written 
with regard to the main pathological condition, which we are able to 
excite and observe in the living tissues, inflammation, appears to have 
originated in the view that the coats of the bloodvessels were the most 
essential elements in the production and maintenance of the phlogistic 
process. This is owing to the experiments having been necessarily of a 
character to irritate the vessels from without, and produce rather a phy- 
sical than a vital effect. We cannot in this way imitate those consti- 
tutional causes of inflammation to which we must generally attribute 
its production, and in which it is impossible not to recognize the state of 
the blood as constituting the first element in the production of the phe- 
nomena in question. These remarks apply more particularly to the 
capillaries, but we shall have occasion to see that they also bear upon 
many of the symptoms met with in the larger vessels. The difference 
in the direction of the current, in the composition of the blood, in the 
velocity and force of the circulation, and in the structure of their coats, 
are points that must not be overlooked in forming an estimate of the 
diseases of the two great classes of vessels, the arteries and veins. The 
manifestations of disease in its primary and secondary form are essen- 
tially different in the two, as we find their physiological and anatomical 
relations to be widely apart. The arteries exhibit between their lining 
membrane and cellular coat a dense fibrous layer, which contains no 
vessels, and therefore removes the vasa vasorum, which ramify in the 
cellular coat, much further from the lining membrane than is the case 
in the veins, nor can any vessels be detected on the lining coat, or between 
it and the middle tunic. To this circumstance, and not to any difference 
in the supply of bloodvessels, we must attribute the fact that, while 
irritation of the lining membrane of the veins rapidly and easily pro- 
duces inflammatory reaction, it is almost impossible to produce such 
effects in the arterial lining membrane. Hasse 1 is of opinion that the 
latter, in both instances, at first merely yields to the alternations of en- 

1 Pathological Anatomy, Syd. Soc. Ed. p. 11. 



332 THE ARTERIES. 

dosinosis and exosmosis, and does not suffer any organic change until a 
later period. In arguing on the effects of inflammation in the arteries, 
we must not forget that the laws of exosmosis and endosmosis apply 
chiefly to fluids occupying the opposite side of the same membrane. In 
the arteries, we find deposits chiefly between the middle and lining coat, 
and of a character to forbid our believing that they can be derived 
directly from the current circulating in the vessel. Here, then, the 
exudation from the vasa vasorum has traversed the dense fibrous coat; 
and there appears to be no reason for refusing to admit that, eventually, 
the lining coat may be involved in a similar process. Without entering 
further into these considerations, we may observe that we are unable 
to join those who look upon the reddening of the internal coat accom- 
panying its thickened condition, which cannot be attributed to post- 
mortem action, to mere imbibition ; but that there must be some change 
in the nutrition of the parts analogous to inflammation in other parts. 



THE ARTERIES. 

To proceed systematically, we shall first examine the morbid conditions 
of the arteries. 

We have seen that it is a subject of debate whether the middle and 
lining coats of the arteries are subject to inflammation ; as they possess 
no bloodvessels of their own, we can scarcely assume them to present 
symptoms of the primary phenomena of inflammation ; but that they 
may be secondarily involved in inflammatory affections proceeding from 
the cellular sheath, cannot be doubted. A most interesting case of 
acute arteritis, in a previously healthy individual, a gentleman, aged 
twenty-nine, is recorded by Dr. Romberg, 1 where sudden pain mani- 
fested itself in the right femoral artery, affecting the distribution of the 
artery in the limb, then mounting up to the aorta, passed to the left 
iliac and its branches. Endocarditis followed, and inflammation of the 
arteries in the left upper extremity; the entire illness lasted from the 
20th October, 1844, to the 5th December, of the same year. The post 
mortem was performed by Professor Froriep thirty hours after death, 
and the following appearances were found in the arteries: A pale red, 
firm clot was discovered in the abdominal aorta, close to its division; it 
blocked up the artery, and adhered closely to its lining membrane, which 
was smooth and not reddened. This coagulum extended into the two 
iliac arteries, gradually became thinner, and terminated in a point. At 
the point at which the left external iliac is given off, there was an equally 
firm but lighter-colored exudation. The left external iliac, as far as 
Poupart's ligament, was filled up with a thinner coagulum containing 
much cruor; it could be easily detached from the lining membrane, 
which was thickened, reddened, and friable, and could be easily detached 
from the fibrous coat. The middle and external coats were also thicker 
and more friable than in the normal state. Between the membranes 

1 Manual of Nervous Diseases, Sydenham Society's Edition, vol. ii. p. 238. Since the 
above was written, a very similar case has occurred under the care of Dr. Sibson, at St. 
Mary's Hospital. 



THE ARTERIES. 333 

there was an exudation of lymph, which was also distinctly perceptible 
in the cellular tissue surrounding the arteries. The latter was particu- 
larly inflamed under Poupart's ligament, and the neighboring lymphatic 
glands were tumefied and reddened. The crural artery contained a firm 
coagulum at the point at which the profunda is given off, which could 
only be detached with difficulty from the dark red lining membrane, and 
which extended into the profunda. Further on, the crural artery was 
filled with a grumous coagulum, and the lining membrane was villous, 
rough, and much reddened. Then came a free spot, but at the part 
where it passes through the adductor, it was again closed by a firm co- 
agulum, and the corresponding lining membrane was much reddened, 
softened, and pulpy. The tissues here were in a state of gangrene, the 
right internal iliac was unaffected. A firm, pale clot, strongly adher- 
ing to the lining coat, was discovered in the external iliac close to the 
point at which it is given off by the common iliac artery. The crural 
artery of the same side was narrow and contracted; the lining mem- 
brane thrown into folds, containing a solid plug at the site of the pro- 
funda; the lining and other membranes being much reddened and 
thickened. A similar coagulum was found in the left branchial artery 
at its division, extending into the radial and ulnar. The heart was 
hypertrophic, and a roundish excrescence was found attached to the 
mitral valve, which was proved by Professor Miiller to consist of fibroid 
tissue, and to be subjacent to the endocardium. The same author con- 
firmed the fact that a thin layer of plastic exudation matter was found 
on the arterial coagula, which at many points also invested the lining 
membrane. For further particulars, and for the author's views on the 
case, we must refer the reader to Dr. Romberg's work. We have ex- 
tracted so much of it as refers to the subject under consideration, and 
because it offers a combination of all those phenomena which writers 
attribute to acute arteritis, and which are found in the inflammations of 
other parts of the system as a result of a peculiar derangement of the 
circulating fluid. In this respect, the case quoted might form an appro- 
priate text for the development of the whole theory of the phlogistic 
process. Bizot 1 describes as the result of acute inflammation of the 
arteries, an albuminous exudation of greater or less thickness, of the 
consistency of jelly, transparent, smooth, sometimes rose-colored, at 
others colorless, covering the lining membrane. It is occasionally so 
transparent as to escape attention unless very carefully examined. It 
occurs in patches, solitary or numerous, and diminishes the caliber of 
the vessel; in one case, Bizot saw it entirely plugging up the anterior 
tibial artery. In the aorta, this exudation is formed mostly at the orifice 
of the arteries arising from the arch, at the mouth of the cceliac, mesen- 
teric, and renal arteries, and at its posterior surface, so as to block up 
the mouths of the intercostal arteries. An instance of acute inflamma- 
tion of the aorta is recorded by Mr. Hodgson ; 2 it is to this effect: A 
man was seized with violent pneumonia, which proved fatal in five days; 
the cadaveric inspection exhibited all the thoracic viscera in the highest 

1 Memoires de la Soci6t6 d' Observation, yol. i. p. 311. 

2 On the Arteries, p. 5. 



334 



THE ARTERIES. 



degree of acute inflammation; the aorta was also involved; its internal 
coat being of a deep red color, and a considerable portion of lymph 
being effused into the cavity. The effused lymph was very intimately 



Fig. 148. 



Fig. 149. 




Plastic deposits in aorta. 



Plastic plugs occluding the axillary artery. 



connected with the internal coat of the vessel, and a plug of it had ex- 
tended into the left subclavian artery, and nearly obliterated the cavity 
of that vessel. In reference to this subject, some experiments performed 
by Gendrin 1 are of considerable importance in demonstrating the capa- 
bility of the coats of the artery giving rise to inflammatory exudation 
in the strict sense of the word. He found that on injecting an irritant 
substance into a portion of an artery included between two ligatures, 
and deprived of blood, a deposit of coagulable lymph took place, which 
arrested the internal coat, and at last formed a plug filling up the 
channel. The lining membrane at first was only slightly discolored, 
and through it a network of injected capillaries might be distinguished 
on the adherent surface of this tunic to the middle coat. When the 



1 Histoire Anatomique des Inflammations, vol. ii. p. 13. 



THE ARTERIES. 335 

inflammation had advanced, this was no longer seen, the external coat 
having become pulpy, rugous, and dull. The suppuration that followed 
did always coincide with ulceration of the inner coat; the pus, however, 
was not necessarily deposited in the vessel, but infiltrated into the cel- 
lular sheath, forming small abscesses. We may reasonably conclude that 
in arteritis the morbid products are derived from the vasa vasorum as 
well as from the contained blood. To sum up: The symptoms of acute 
inflammation of the arteries are more or less extensive, reddening, soft- 
ening, thickening, and detachment of the lining coat which exhibits an 
opaque, plicated condition; the middle coat becomes hypertrophied and 
friable, and in the external coat we find distinct signs of congestion and 
exudation. Within the vessel, a coagulation of fibrin and the deposit of 
coagulable lymph from the blood is seen, and as secondary effects we 
have to deal with ulceration, laceration of the coats, hemorrhage, and 
gangrene of the distal parts of the system. 

From the time of J. P. Frank, 1 who first drew attention to the sub- 
ject of arterial inflammation, to the most recent periods, various patho- 
logical conditions have been attributed to it ; the acute forms have been 
repeatedly asserted to be the cause of trismus neonatorum, a disease 
which at present is one of very rare occurrence among ourselves. Dr.. 
West denies this cause, but Dr. Collis, 2 and recently Dr. Scholler 3 satis- 
fied themselves of its real existence. The latter found inflammation of 
the umbilical arteries in fifteen out of eighteen cases of trismus neona- 
torum. There was tumefaction of the umbilicus, reddening and con- 
gestion on the external surface ; the channel contained pus, and the 
lining membrane was eroded and invested with an albuminous exudation. 
Dr. Scholler has carefully examined these parts in all other new-born 
children who died shortly after birth, and has never succeeded in dis- 
covering similar lesions. It does not appear that traumatic tetanus in 
the adult, to which we may compare trismus neonatorum, is accompanied 
by similar lesions. 

The formation of a coagulum in the artery is a well-known physiolo- 
gical effect of the laceration by mechanical or other means of the lining 
membrane, and the atrophy or gangrene of the part nourished by the 
artery is an illustration of the effects following similar obliteration of 
the channel from disease. We have alluded to the cerebral affections 
resulting from an arrest in the arterial circulation ; senile gangrene is 
another morbid condition which has been ascribed, by Dupuytren and 
Cruveilhier, to arteritis. In this there is a marked distinction between 
inflammation of the two sets of vessels ; that phlebitis induces secondary 
deposits and oedema, while these occurrences are not met with in arte- 
ritis. It is even doubted whether the latter ever gives rise to suppura- 
tion, but, independently of the cases of suppuration in the umbilical 
artery quoted from Dr. Scholler, Andral and Hodgson's 4 authority 5 de- 

1 De curandis Homiuum Morbis, vol. ii. p. 363. 

2 Dublin Hospital Reports, vol. i. p. 285. 

3 Neue Zeitschrift fur Geburtskunde, herausgegeben von Busch, d'Outrepont und Bit- 
gen, vol. v. p. 477. 

•Anat. Pathologique, torn. ii. p, 379. 
5 On the Arteries, p. 10. 



336 THE ARTERIES. 

termine the question affirmatively, for these authors state that actual 
idiopathic suppuration does occur in the artery. 

The spontaneous coagulation of the blood in the arteries is not, how- 
ever, the result of inflammatory action only. It may occur in conse- 
quence of a low ataxic condition, which does not permit the vital powers 
to resist the chemical tendencies that normally ought not to come into 
play until after death. This spontaneous coagulation is especially met 
with in the pulmonary arteries, where the occurrence of the inflamma- 
tory symptoms has, as yet, not been met with. Mr. Paget, 1 in describing 
a case of the kind, says, that nearly all the branches beyond the primary 
divisions of the pulmonary artery contained clots of blood, which, from 
a comparison with those found in tied arteries, he judged to be from 
three to ten days old. The clots did not commonly extend continuously 
from any large branch of the pulmonary artery into many of its succes- 
sively subordinate divisions, no branch of the pulmonary artery less 
than half a line in diameter appeared to contain any of these clots, and 
the pulmonary veins were healthy and empty. The case under consid- 
eration proves that a large portion of the pulmonary circulation may be 
arrested for a considerable period without immediate danger to life, a 
circumstance explained by Mr. Paget, by assuming a retardation of the 
circulation in the systemic vessels, in order to allow the quantity tra- 
versing them in a given time to be equal to the reduced quantity which 
in the same time traverses the lungs. In order to keep up the necessary 
balance, the systemic circulation is as much less rapid than the remain- 
ing pulmonary circulation is more rapid than before the obstruction 
took place. 

The formation of a coagulum in the artery does not necessarily block 
up the entire passage, but may leave a central opening by which the 
circulation yet continues to be carried on. But after the formation of 
the clot, it in its turn undergoes various changes ; it may become 
absorbed, or it softens or breaks up into granular matter, and is carried 
into the capillary circulation, or it is capable of organization, and we 
then find in it a network of fine bloodvessels. The last point serves to 
elucidate the observations of the passage of an artery occasionally seen 
in old coagula formed after the application of a ligature. Lobstein, as 
we are informed by Hasse, met with an arterial vessel of the caliber of 
the stylo-mastoid artery running lengthwise through the femoral artery 
obliterated two years previously by tying. Blandin and Barth have 
met with analogous instances, to which may be added those cases in 
which, after the complete obliteration of arteries by ligature, new ves- 
sels have been found shooting from their extremities. The general 
infection of the blood from breaking up of arterial coagula, is a very 
rare occurrence; a circumstance which establishes a marked distinction 
between arterial and venous disease ; it is referred by Rokitansky to 
the greater susceptibility of the arterial blood for taking up inflamma- 
tory products, which speedily give rise to coagulation and obturation of 
the vessel, and to the circumstance that their reaction in the arterial 

1 See Mr. Paget on obstructions in the Pulmonary Arteries, Medico-Chirurgical Trans- 
act, vol. xxviii. p. 533. 



CHRONIC ARTERITIS. 337 

current, being exhausted towards the capillaries in ordinary cases, 
hinders the general infection of the blood beyond the limits of those 
vessels. 

CHRONIC ARTERITIS. 

With regard to chronic arteritis, the opinions of writers are yet more 
divided than in reference to the acute form. The same difficulties in 
determining the relation of cause or effect in this subject has been felt 
by most of the writers on the subject, and have not yet met their com- 
plete solution. The older authors attributed the appearances of chronic 
arteritis to syphilitic taint or mercurial poisoning ; some of the more 
recent, among whom we may mention Corvisart, 1 have held a similar 
opinion, and Hodgson 2 supports it on the ground that he has observed 
aneurism, and those organic alterations which generally attend the 
formation of aneurism, to prevail in subjects that have suffered from 
venereal disease, and who have taken large quantities of mercury. 

While the majority of authors are of opinion that fibrinous deposit, 
atheroma, ulceration, ossification, and aneurism are the result of a chro- 
nic inflammatory process, Hasse absolutely denies its primary existence, 
and only admits its occasional occurrence as a secondary effect of the 
degenerative processes alluded to. On the other hand, Rokitansky looks 
upon chronic inflammation of the arteries as an essential constituent of 
morbid deposits on the inner coats of the vessel, and its metamorphoses, 
but is of opinion that it is primarily manifested in the cellular sheath of 
the arteries, where it produces hypertrophy, thickening, and condensa- 
tion, followed by a secondary disturbing action upon the normal relation 
of the inner arterial coats, the fibrous and true lining membrane. It 
is very certain, however, that we very rarely meet with traces of this 
superficial cellular inflammation of arteries, except as a result of their 
implication in morbid processes of the surrounding tissues, as in phleg- 
monous erysipelas, or in tubercular destruction of the parts ; while we 
constantly have occasion to examine deposits underneath the lining mem- 
brane in their incipient stages. Here, we almost uniformly find an accom- 
panying tumefaction and reddening, affecting the entire thickness of the 
inner coat, which is distinctly perceptible on making a section of the 
artery. This change is accompanied by a puckering and plicated con- 
dition, and extends to a greater or less distance beyond the circumference 
of the deposit. The reddening, though persistent, is not due to the 
formation of new vessels ; the microscope fails to detect them. The 
softening, which we find to be a common result of inflammatory action, 
affects the entire caliber of the artery, and in that case may give rise 
to a uniform dilatation, or to what has been termed true aneurism. The 
deposit which invariably takes place in the first instance, between the 
middle and internal coats, is of a yellowish tinge, and forms slight ele- 
vations, in circumscribed dots or patches ; as the disease advances, these 
coalesce, and may thus affect the vessel to a considerable extent. We 
are not prepared to state, nor are we of opinion, that the chemical 

1 Essai sur les Maladies du Coeur, p. 319. 2 On the Arteries, p, 9, 

22 



338 



CHRONIC ARTERITIS. 



character of the primary deposit is in all cases identical ; this would 
not be in accordance with what we know of the elimination of. morbid 
constituents of the blood. But there is no doubt that in a majority of 
cases the atheromic deposit is a secondary fatty degeneration of fibrin. 
We are inclined to suggest that the more purely inflammatory the cause 

Fig. 150. 




Incipient atheroma and fatty degeneration of an iliac taken from an aged female. The lining membrane is 
much puckered, owing to the irregular deposit of fibrin between it and the middle coat. A. Naked-eye yiew 
of the artery. B. Microscopic appearance of the fibrinous deposit, dotted with oil-molecules, c. A longitudinal 
section of the artery taken between *— *; j, the inner coat with subjacent deposit ; m, middle coat unaltered; 
o, the external coat. 

of the disease, the more presumption there is of a fibrinous deposit in 
the first instance. The fibrin seen by the naked eye presents little or 
no distinction from actual atheroma ; but, on examination by the micro- 
scope, we see the delicate fibrillse characteristic of this matter : and we 
also detect in it glistening particles of oil, which show the transition to 
atheroma. The fibrin is itself deposited in distinct laminae, which may 



Fig. 151. 




Fig. 152. 




Fatty deposits in internal coat. 



Early stage of atheroma. 



easily be separated from one another in the plane of the vascular coats ; 
there is no arrest of the coat investing it on the minor surface of the 
artery, but this may be peeled off to an indefinite extent beyond the 




CHRONIC ARTERITIS. 339 

deposit, showing that in the earlier stage there is no solution of con- 
tinuity of the lining membrane, a point of some importance in reference 
to the doctrine expounded by Rokitansky. This author, who treats of 
the diseases in question as a new formation of the lining membrane from 
the blood, does not appear to have recognized this form of deposit, which 
we have delineated, and which is clearly subjacent to the inner coat. Dr. 
Hope, who does not, however, appear to have confirmed his view by a 
microscopic examination, looks upon the fibrinous deposit as the first 
stage of the metamorphosis ; and, until further investigations confirm the 
views of the Viennese Professor, we adhere to the doctrine just adverted 
to, in preference to what we cannot but regard as a forced explanation. 
It is, however, but due to the high reputation of Professor Rokitansky, 
that we should allow him to speak for himself 
in this question, in order that further investi- Fig. 153. 

gation may determine the point; he says: 1 
" The most frequent form of disease affecting /^iiLs 

the arteries is an excessive formation and depo- / s| 
sition of the lining membrane of the artery, / "^ ° ° o 
derived from the mass of the blood, and at / /^H'^ ^^ 
the same time constituting hypertrophy of j rK^o°°^^o-^^ 
this membrane. In a highly developed form ', ^57 0° °'-£' I 
of this affection, we find the inner surface of \ ;. Q Q % °.y T: l'.' / 
a large artery, as the aorta, covered with a \ ' ^) : '}yj/ 

foreign substance, spread over it at separate ^^. ^-^ 

points or in large patches, and forming a Atheroma from old patch. 

stratum varying in thickness, by which the 

inner surface of the vessel is commonly rendered uneven ; this substance 
is, in some places, either grayish, grayish-white, faded and translucent, 
or, in others, milky white, opaque, and similar to coagulated albumen ; 
in some rare instances it is colored by the imbibition of h^ematin, over 
various extents of surface. Its free surface is at the same time smooth 
and shining, or dull, and, as it were, wrinkled. It is soft, moist, and 
succulent in the translucent parts, and dense, dry, tough, and elastic in 
the more opaque portions; resembling a cartilage or fibro-cartilage, with 
which it is usually compared, and for which it is still occasionally mis- 
taken. In the latter condition, it adheres internally to the circular 
fibrous coat." Hasse considers that when chronic arteritis is induced 
by degenerative processes, we find a deep, dingy, brownish-red color, 
extending to the middle tunic, a densely injected state of the vasa vaso- 
rum of the cellular sheath, and a deposition of plastic material in the 
caliber of the vessel ; these deposits accumulating in masses, adhering 
to the arterial parietes, and consisting of imbricated layers. 

We occasionally find a general thinning of the coats of an artery 
without any appreciable change in their composition, in the same way 
as we also find an hypertrophic condition of the same character. In 
either case it appears generally to be at the expense of the middle 
fibrous coat. But, in the great majority of instances, we shall, on 
careful examination, succeed in detecting some existing, or some ante- 

1 Pathol. Anat. vol. iv. p. 261. Sydenh. Society's Ed. 



340 



ATHEROMA. 



cedent, morbid deposit to which the condition is attributable. The 
most important of these is what is commonly called the atheromatous 
process. 

ATHEROMA. 

Atheroma, 1 or, as it has also been called by Baillie and others, stea- 
toma of the arteries, is not, as we have already seen, necessarily a soft, 
pulpy deposit ; but appears, in the first instance, as a series of fibrinous 
layers subjacent to the inner coat of the artery, formed by a process 



Fig. 154. 



Fig. 155. 



-A -<**&* 





Steatomatous degeneration. 



Fatty granules, with crystals of cholesterin, 
from atheromatous deposits in the aorta. — 
Bennett. 



analogous to secretion from the blood. Small oil-globules are early 
seen in the fibrin, and in the course of time the latter may become com- 
pletely converted into oil and a fatty crystalline matter, termed choles- 
terin, which appears in flat, rhomboidal, crystalline laminae, with sharp 
outlines ; the oil occurs in small globules of a highly refracting charac- 
ter, more or less aggregated in masses, and soluble in ether. In this 
state it presents a pulpy diffluent condition, and, owing to its yellow 
color, it may, as it occasionally has, be mistaken for pus. This con- 
version does not necessarily follow at stated periods, for it is probable 
that the fibrin may continue unchanged for a long time, until such a 
tendency prevails in the constitution of the individual of a cachectic or 
degenerative character, as to give rise to the secondary process. The 
lining membrane of the artery investing the atheroma, in the first 
instance, becomes thicker, and assumes a darker color, and is capable 
of considerable distension by the morbid product. This at first occurs 



1 Atheroma is derived from aQvpv, wheat-grits, a pap made of them, hence aQhpoo/ua., an 
unclassical term, a pulpy substance. 



OSSIFICATION OF ARTERIES. 341 

in small points, and, by gradual extension, may occupy surfaces of one 
or more inches in circumference, and of irregular though definite out- 
line. The liability 1 of the arterial system to be affected, is in a ratio 
with the proximity to the aorta, this vessel presenting the greatest pro- 
clivity. In no disease does the general law of symmetry, which prevails 
in morbid as well as in physiological growth, manifest itself with so 
much exactness, as in the one under consideration ; the existence of an 
atheromatous patch in an artery, may lead us safely to infer the presence 
of an analogous change in its fellow. And this applies equally to those 
lesions which are consecutive to the primary deposit, as softening and 
ossification ; thus, to quote a single instance from Bizot's memoir, he 
examined thirty-four cases in which the crural arteries were the seat of 
patches, and in thirty- three the law of symmetry was observed; in 
twenty-four cases of consecutive lesion of the same vessel, there was no 
exception to the law. Even in the aorta we are able, in the incipient 
stages of the disease, to trace the same law ; the patches being found 
symmetrically placed round the orifices of each pair of intercostal 
arteries, or forming parallel lines across the main vessel. The two 
sexes do not differ in any marked manner with regard to the frequency 
of the occurrence of the patches. The only exception from this is, the 
well-ascertained proclivity on the part of the female sex to disease of 
the inferior mesenteric and the abdominal aorta ; the ratio of its occur- 
rence in males and females is nearly as one to four. On the other 
hand, age exerts an undeniable influence in its production; so much so, 
that, while it is scarcely ever met with before puberty, we rarely open 
the body of a person in advanced age without finding some arterial 
lesion of the kind. The liability increases in the exact ratio of the age 
of the individual, so much so that we can scarcely refuse to look upon 
the change in a measure as essentially connected with the process of 
involution. Mr. Hodgson 2 gives two instances of the deposit of cal- 
careous matter in the arteries of infants, but they are extremely rare, 
and thus only add force to the rule laid down. 



OSSIFICATION OF ARTERIES. 

The second change which the arterial patches undergo, is that of 
ossification ; a process in which phosphate of lime is deposited in an 
amorphous condition ; it contains no bone-corpuscles or canaliculi, and 
hence, though the proportion between the animal and earthy matter is 
about the same as that prevailing in true bone, it is by no means identical 
with it. As the process advances, the internal arterial coat is generally 
destroyed, and the mass projects, in the most varied and fantastic forms, 
into the current of the blood ; thus, in its turn, giving rise to further 
deposits in the shape of fibrinous coagula; or the bony deposit advances 
under the lining membrane, till it encircles the artery and converts it 
into a rigid channel, inducing that condition which is found to accom- 

1 See Bizot, Memoires de la Societe cU Observation, vol. i. p. 388. 

2 On the Arteries, p. 23. 



342 



OSSIFICATION OF ARTERIES. 



pany senile gangrene, fatty degeneration of the heart, cerebral soften- 
ing, and other morbid processes. The frequency with which different 
arteries are affected, follows the general rule already laid down, that 



Fig. 15G. 



Fig. 157. 





Calcareous deposition. 



Annular calcification; it principally oc- 
curs in arteries of the third magnitude, 
such as the popliteal and the femoral. It 
commences hy the deposit of granules of 
calcareous matter, a, which are arranged 
in lines running transversely to the axis 
of the vessel; the lines gradually increase 
in breadth until they coalesce laterally, 
the intervening spaces being filled up, and 
the vessel being converted into a rigid 
tube, b. 



the liability bears a certain ratio to the proximity of the vessel to the 
centre of the circulation. This, however, applies only to the systemic 
circulation; and here, too, there are some marked exceptions, for the 
coeliac, the hepatic, and the mesenteric, gastric, and hypogastric arteries 
are scarcely ever found ossified, while the splenic presents this condition 
very commonly ; we must assume that the nature of the contained blood 
exerts some influence upon the process. Lobstein, who has made out a 
list showing the comparative frequency of the affection in the different 
arteries, places the pulmonary arteries last. He also includes branches 
of the umbilical artery, and the vessels of the placenta. Very small 
arterial twigs present gritty deposits in their coats ; but ossification has 
not been met with in the capillaries. 

One of the secondary effects of atheroma and ossification is, a perfo- 
ration of the lining coat of the artery, causing, in some instances, an 
appearance of ulceration ; Rokitansky and Gluge deny the existence of 



OSSIFICATION OF AKTERIES. 343 

ulceration in the arteries, on the ground that there is no essential 
analogy between the atheromatous and ulcerous process, and that the 
deposit itself is not an inflammatory product ; but the former author 
adverts to a peculiar appearance in highly diseased arteries not spoken 
of by other writers, which he characterizes as minute openings or fora- 
mina, interspersed between the deposit, resembling the contracted 
mouths of small vessels. They lead into canals which penetrate the 
deposits to various depths, and serve to convey the blood into it and 
into the circular fibrous coat. The description would lead the reader to 
suppose that the object of the atheromatous process was to produce this 
condition, instead of its being a mere result of disintegration. 

A remarkable fact in connection with the forms of arterial disease 
just discussed is, that it appears to confer an immunity from tubercle, 
while it is closely allied to fatty degeneration ; the latter is a point to 
which attention has been especially directed of late among ourselves ; it 
is one that Rokitansky most pointedly alludes to in the first edition of 
his great work. There does not appear to be sufficient ground for 
adopting the doctrine of the older writers, and which Dr. Copland 1 
sanctions and enlarges upon, that ossification of the arteries is derived 
from the same sources as the morbid deposit of stone and gout. The 
only analogy appears to be that they originate in the blood ; but the 
crasis giving rise to it, as well as the chemical nature of the product, 
are essentially different. We have already alluded to the circumstances 
of atheroma inducing aneurism. This disease is one that has long 
attracted the serious attention of medical practitioners in its advanced 
stages, in which it becomes not only irksome to the patient, but a source 
of great danger. Important as the surgical aid is, that in many 
instances may be rendered, it is easy to understand, from the constitu- 
tional character of one of its causes, why operations so frequently fail. 

1 Dictionary of Medicine, vol. i. p. 121. 



CHAPTER XXIII. 

ANEURISM. 

Aneurism, 1 or a dilatation of an artery, is connected with two lesions, 
according to which, from the days of Scarpa and John Bell, downwards, 
two classes of aneurismatic disease have been adopted by most writers 
— true and false aneurism — though we shall find grounds for assuming 
that spontaneous aneurism is in all instances traceable to one ultimate 
cause — a morbid state of the arterial coats, which may produce accidental 
varieties in the arterial tumor. The definition of true and false aneu- 
rism, ordinarily accepted, is that, in the former, we have to deal with a 
dilatation, partial or entire, of a certain extent of an artery, without 
laceration of any of its coats, while in the latter, the dilatation is accom- 
panied by the laceration of one or more of the coats. The distinction 
is not, however, one based upon a difference in the morbid process ; the 
laceration, except in traumatic aneurism, being an accidental coincidence. 
The effect of the atheromatous process is to destroy the normal cohesion 
of the artery, the lining and middle coats are weakened, and the latter 
may become much atrophied, in addition to being in a degenerative 
condition. The column of blood acting upon a point thus weakened, 
necessarily causes the coats to protrude, and the protrusion will corre- 
spond in size and extent to the amount of previous disease in the artery. 
Several small dilatations occurring near one another, may, in the course 
of time, unite and thus form one large pouch. Dr. Peacock 2 has shown 
that, in these cases, there is an entire continuity of the lining membrane 
in the sac, and that, while all three coats may present the normal rela- 
tion at the orifice, the middle coat becomes so much atrophied as in some 
cases to disappear altogether at the distal point of the aneurism, so that 
the internal and external coats come into contact with one another. 
This is the form which Rokitansky considers identical with the hernial 
aneurism of authors or with Scarpa's aneurisma spurium. In the sim- 
plest form of dilatation the entire caliber of the artery is affected, and 
the fusiform variety results, or the aneurism is confined to one side of 
the vessel, and it then assumes the saccular character, with an opening, 
which is more or less patulous, and may be so constricted as to resemble 
mere pedicle. It is to the latter that Mr. Hodgson, and some other 
writers, confine the term aneurism ; but there are not sufficient grounds 
in the nature of the morbid change to sanction this view. Scarpa, fol- 
lowing Sennertus, limits the term to those aneurismal tumors which 

1 The term is derived from avevpvw, I dilate ; avsCpve-pa, a dilatation. 

2 Patholog. Reports, 1850, p. 201. 



ANEURISM. 345 

result from rupture of the coats. This is almost invariably found in 
large aneurismal sacs, and appears to be a main cause of that stratified 
coagulation of blood met with in them, the clot forming by that law 

Fig. 158. 




Section of the arch of an aorta, with an aneurism arising from its upper part. The cavity of the sac is 
nearly filled hy laminated coagulum, the internal membrane of the artery is thickened. The sac presses 
against the trachea, the arteria innominata, and the right carotid and subclavian arteries. — St. Bartholomew's 
Museum, Series xiii. No. 11. 

which enables the human economy to protect itself against dangerous 
and noxious influences. A solid deposit is less frequently met with in 
aneurisms formed by simple dilatation of the coats of the vessel. 

The form of sacculated aneurisms is generally globular, but they may, 
partly owing to accidental conditions in the coats of the affected vessels, 
partly from the pressure exerted by surrounding tissues, assume an oval 
or more or less irregular outline. Upon the original aneurism, an evolu- 
tion of secondary dilatations is sometimes met with, and these may even 
give rise to a further or tertiary multiplication of the disease, so as to 
induce a sort of mulberry appearance in the tumor.; it is the variety to 
which Cruveilhier has applied the term " aneVrisme sous l'aspect d'am- 
poules k bosselures." 

The laceration of the internal coats of the artery ma^ occur at the 
early stages of the disease, and be the first exciting cause of the aneu- 
rismal tumor. The aorta of a lady, whose case is detailed by Mr. Hodg- 
son, 1 illustrated this mode of the formation of aneurism. The coats of 
the vessel were diseased, and presented at the arch a transverse rent, 
about an inch in length, which had penetrated to the middle coat. The 
blood had insinuated itself between the middle and external coats, the 
latter of which was elevated into a tumor, about two inches in circum- 
ference. A similar appearance was found in the body of George II. 
We see no difficulty in regard to this view of the occasional origin of 
aneurism. That the early stages should not often be presented to us in 

1 On the Arteries, pp. 39 and 63. 



346 



ANEURISM. 



the dead subject, is easily accounted for by the rapid distension that will 
take place after the first laceration, and the equally rapid laminated 
deposit of the defensive fibrin. Rokitansky, however, denies this mode 



Fig. 159. 



Fig. 160. 





Aneurism of the Brachial Artery. 



Aneurism of the posterior tibial artery, with the 
nerve spread over the back part of the pouch; the 
sac is entirely obliterated by concentric layers of 
fibrin, growing paler towards the surface.— St. George's 
Museum, F. 41. 



of origin altogether, stating that no such rent is ever detected. Another 
question is, whether laceration of an artery ever occurs without some 
previous derangement in its coats, in what is termed the traumatic form 
of aneurism, without a penetrating wound. The extreme pliability and 
elasticity of the arterial system, compared with all the tissues that sur- 
round it, might alone suffice to answer the question ; but the direct phy- 
siological experiments performed by Mr. Hodgson and Mr. Hunter, and 
Sir Everard Home, 1 as well as the pathological observations by the 
former, 2 positively determine the point in the negative. Mr. Hodgson 
states that he has repeatedly tried, in imitation of Eicherand, to produce 
a laceration of the internal and middle coats of the popliteal artery, by 
violently extending the leg upon the thigh; but that he has never lace- 
rated the coats of the artery unless the degree of violence was sufficient 
to rupture the ligaments of the knee, an event which certainly does not 
generally accompany those accidents to which patients attribute the 
origin of aneurism. 

The contents of aneurismal sacs are fibrinous coagula, which form 
in successive layers, and accordingly present a concentric arrangement, 
like the annular rings in perennial plants. The resemblance may be 
traced still further in the gradual condensation of the outer or external 

1 Transactions of a Society for the Improvement of Medical and Surgical Knowledge, 
vol. i. p. 144. 

2 On the Arteries, p. 64. 



ANEURISM. 



347 



layers, owing to absorption and compression. These also lose their 
color, and become fawn-colored or white; while towards the interior we 
continue to recognize the dark color of the blood. The accumulation 
may proceed to such an extent as to obliterate the cavity, and thus es- 



Fig. 161. 



Fig. 162. 





Further growth of aneurism prevented by eoagulum 
becoming adherent to the artery around the opening of 
the sac. — From Hodgson. 



Spontaneous cure of aneurism of the 
femoral artery by the sac being filled -with 
eoagulum ; the vessel remaining pervious. 



tablish a spontaneous cure. A considerable amount of organization is 
observed to take place in some deposits, manifested by the formation of 
fibres. The existence of a distinct membrane is assumed by most writers 
to envelop the eoagulum. It is a point to which Bizot particularly drew 
attention, and upon which Hasse dwells forcibly. The latter states that 
he has never met with an aneurism in which this adventitious membrane 
was not present. Mr. Bowman has observed that the membrane en- 
veloping the coagula in an aneurism, though apparently of exactly the 
same nature as that lining the arteries, diners from it in not presenting 
any epithelium. We would not lay any stress upon this distinction, 
inasmuch as the presence of epithelium in a healthy artery is often, to 
say the least, extremely doubtful. The coagula form in proportion as 
the sac is cut off from the rest of the circulation, the more shallow it is, 
and therefore the more exposed to the force of the current, the less the 
liability to the formation of fibrinous laminse, and the less, we may also 
add, the coincident danger of perforation of the coats of the vessel. It 
is through the agency of this deposit that a spontaneous cure may take 
place, either by an obliteration of the sac, or by pressure upon the artery, 
and consequent obliteration of its channel. The coagula may subse- 
quently undergo secondary metamorphoses, such as a conversion into 



348 



ANEURISM. 



5 


21 


1 


15 





12 


1 


8 





5 





2 



cholesterin, or cretaceous matter. But it does not always form, and 
we may meet with a series of aneurisms on the same vessel, some of 
which present the deposit, while others are empty. In number and size 
there is a great diversity, as also with regard to the liability of different 
arteries to be affected, as well as in respect of sex. The following table 
contains an analysis of sixty-three cases, examined by Mr. Hodgson, 
which illustrates the last two points. It shows at once the great liability 
of the male sex, and the prevailing tendency of certain arteries to be 
affected : — 1 

Males. Females. Total. 
Ascending aorta, innominata, and arch of the aorta 16 
Femoral and popliteal . . . . . 14 

Inguinal . .12 

Descending aorta 7 

Subclavian and axillary 5 

Carotid 2 

56 7 63 

Bizot's statistics agree closely with those of Mr. Hodgson as to the 
different liability of the two sexes ; out of one hundred and eighty-nine 
analyzed by him, one hundred and seventy-one occurred in men, and 
eighteen in women, which is even more in favor of the latter than Mr. 
Hodgson's table. The proclivity to aneurism is also determined by the 
age of the individual; it is unknown to childhood; the greatest tendency 
to the disease exists at the middle period of life, as shown by the follow- 
ing analysis of one hundred and eight cases: — 

From 10 to 19 years i 1 subject 

15 subjects 

35 

41 

14 

8 

2 

2 

As an aneurism enlarges it necessarily displaces the adjoining tissues, 
and causes an absorption of those that offer any resistance. The dan- 
ger of an aneurismal tumor depends upon its site, and upon its vicinity 
to vital organs whose functions are liable to be interfered with by 
pressure. It is thus that aneurism occurring in the thorax and in the 
regions of the neck threatens life, before the arterial disease has put 
on any dangerous appearance, by narrowing the trachea, by compress- 
ing the oesophagus or other vessels. The extent to which absorption 
prepares a passage to an advancing aneurism is in some cases extraor- 
dinary; an aortic aneurism by this process may pass through the thorax 
or eat into the vertebral column. In these cases, as Rokitansky de- 
scribes, not only the bone is destroyed but the aneurismal sac itself 
becomes fused with the periosteum, and the other fibrous structures that 
usually invest the bones. In this way the exposed vertebral column 

1 The table is essentially the same as that given by Mr. Hodgson, but differently 
arranged. It excludes aneurisms arising from wounded arteries, and aneurisms by an- 
astomosis. 



" 20 " 


29 


" 30 " 


39 


« 40 " 


49 


« 50 " 


59 


« 60 " 


69 


" 70 " 


79 


« 80 " 


89 



ANEURISM. 



349 



may constitute a portion of the aneurismal wall. Hodgson 1 has pointed 
out, that, as the aneurism advances to the surface of the body, it induces 



Fig. 163. 



Fig. 164. 





Fig. 163 exhibits a front, and Fig. 164 a back view of an aneurism of the arch of the aorta, which burst 
into the trachea. The opening into the aneurism from the artery, and the atheromatous patches between 
the coats of the latter, are well shown. 

sloughing of the integuments, and an eschar forming on the tumor itself, 
its discharge gives rise to fatal hemorrhage; the same is the case when 

Fig. 165. 




Aneurism of the aorta, which induced caries of the vertebrae, and fatal compression of the spinal cord. 

the aneurism opens into a cavity lined with mucous membrane. But a 
different result takes place when the sac projects into a serous cavity; 
in this case the membranes do not slough, but the parietes of the tumor 
become softened and thinned, and a laceration is effected. If a rupture 



The Diseases of the Arteries, &c. p. 85. 



350 



ANEURISM. 



of the internal and middle coats alone takes place, the external coat 
remaining entire, the blood may separate the latter to a greater or less 
extent without forming a sac ; it then causes what has been termed, by 



Fig. 166. 



Fig. 167. 





Front view of aneurism of aorta. 



Back view of same preparation, showing the aneurism, 
producing absorption of the ribs, and making its way to 
the surface. Death was caused by part of the coagulum 
falling into tbe artery. 



Laennec, the dissecting aneurism. We sometimes meet with small 
ecchymoses under the lining membrane of the aorta in the dead body, 
which indicate the commencement of this form of aneurism. A minute 
and sometimes imperceptible fissure in the inner coat allows of the per- 
meation of a small quantity of blood, and the first step having occurred, 
a succession of similar deposits may soon cause a greater accumulation, 
and necessarily a coincident separation of the coats. Nothing has been 
added by later w r riters to the observations of Mr. Hodgson on the sub- 
ject of the spontaneous cure of aneurism; we cannot do better than to 
extract his own terse summary of the subject; first, the whole tumor 
may be removed by sphacelation, in consequence of extreme inflamma- 
tion excited by the distension of the surrounding parts; secondly, the 
tumor, as we have already had occasion to observe, may assume such a 
position as to obliterate, by its pressure, the superior or inferior portion 
of the artery communicating with the sac; and thirdly, the gradual 
deposition of fibrin in the sac and the artery leading to it, may render 
them impervious, and allow a subsequent process by which the tumor is 
removed. In the latter cases a gradual absorption of its contents takes 
place, the tumor becomes harder and smaller, and the establishment of 
a collateral circulation restores the balance of the circulation. 

Before quitting the subject of aneurism, we- must allude to certain 
peculiarities in connection with its occurrence in different parts of the 
arterial system. We have seen that aneurisms are almost limited to 
arteries of the largest size; in smaller arteries, as in the radial and 
ulnar or tibials, they are rarely met with. They are altogether ex- 
tremely rare in the upper extremity ; they here almost invariably arise 



ANEURISM. 351 

from carelessness in venesection, especially if, as on the continent, a 
spring-lancet is employed. In such a case the result generally is a 
communication between the brachial artery and a cubital vein, espe- 
cially the basilic, forming what is called varicose aneurism. The 

Fig. 168. 




From Liston. 



smallest arteries in which spontaneous aneurism is met with are the 
coronary of the heart and the cerebral. An instance of the former, 
which is extremely rare, is reported in the Records of the Pathological 
Society for 1848 ; it was discovered by Dr. Peacock in a man aged 
fifty-one, who had presented no symptoms of cardiac disease before 
death. The tumor occupied the left coronary artery, and was about 
the size of a pigeon's egg, containing lacerated coagula, which were 
intimately adherent to the lining membrane. There was some atheroma 
in the aorta. Aneurism of the cerebral arteries, though not common, 
has of late been shown to be more frequent than was at one time sup- 
posed. It is generally seated at or near some part of the circle of 
Willis; it may attain the size of a walnut, and more, though it is com- 
monly smaller ; it is met with chiefly between the age of forty and fifty. 
Here, too, the male sex presents a much greater liability than the 
female ; showing that the former manifestly possess a marked aneu- 
rismal diathesis, and that the increased tendency is not due to accidental 
circumstances. We find two good instances of aneurism of the cere- 
bral arteries in the Reports of the Pathological Society, presented by 
Dr. Hare 1 and Dr. Roe; 2 the one in the left posterior communicating 
artery, the other in the anterior cerebral ; this one of unusual size, 
being as large as a hen's egg, had caused partial absorption of the 
sphenoid bone upon which it rested, and a flattening of the adjoining 
portions of the brain. Both the cases alluded to occurred in females ; 
and Dr. Roe's case was still further remarkable from its affecting the 
patient at the early age of twenty-one. Dr. Brinton, 3 from an analysis 
of about forty well-authenticated cases of cerebral aneurism, finds that 
three-eighths terminate in rupture, one-eighth from simple loss of func- 
tions by pressure, one-eighth by convulsive attacks, one-eighth by con- 
gestion or hemorrhage of the brain, one-eighth by inflammatory condi- 
tions of the brain, and one-eighth by coincident disorders or accidents. 
In three instances Dr. Brinton found the aneurisms more than one in 
number ; in one instance three were found ; in one, the opposite carotids 
were symmetrically affected. 

1 Report, 1849-50, p. 169. 2 j; bid ^ 1850-51, p. 46. s Ibid., p. 48. 



352 ANEURISM. 

The pulmonary artery and its distributions are not subject to aneu- 
rism, beyond an occasional dilatation of the orifice adjoining the heart. 
The mechanical injury of an artery may cause the effusion of blood into 
the surrounding parts, which constitutes what has been termed diffuse 
false aneurism. It generally produces gangrene ; but inflammatory re- 
action may be set up, and establish definite limits, and thus lead to the 
formation of an aneurismal sac. It is manifest that this, as well as the 
aneurismal varix, of which we have already spoken, has no pathological 
relation to the disease of which we have been treating. 



CHAPTER XXIV. 

THE VEINS. 

The physiological relations of the veins, as well as their anatomical 
structure, would lead us to assume that their diseases differ in many 
points from those affecting the arterial system. The absence of an elas- 
tic coat, their greater collective capacity, the direction of the contained 
current, their frequent superficial position in the body, the nature of 
their contents, and the absorbent power of these vessels, are elements 
which influence their morbid states materially. Some of the most viru- 
lent manifestations of disease that we are acquainted with are symptoms 
of diseases of the veins, and it is most probable that in the great majority 
of cases of poisoning, whether the toxic agent be introduced by the 
stomach, by the skin, or by inhalation, they are the medium by which 
it is conveyed to the central organs and prostrates the vital energies. 
It is in the study of this subject that the value of pathological inquiry 
has been particularly demonstrated. Hunter was the first to open the 
way, and since that period the scalpel has shown that many previously 
unintelligible malignant conditions are attributable to phlebitis. 

Phlebitis may be acute or chronic. Inflammation of a vein is charac- 
terized by a reddening of all the coats, owing, on the external surface, 
to capillary congestion in the lining membrane, to a transudation similar 
to that found in the coats of the arteries. It is only when we find other 
concomitant symptoms of inflammation, that we are justified in setting 
the latter down to that cause. According to Lebert, 1 the nutrient ves- 
sels of the veins, which in the normal state are scanty, during inflamma- 
tion become excessively developed, forming large anastomosing net- 
works. As the inflammation advances, a second vascular network ex- 
tends from the former, and is described as passing to the surface of the 
lining membrane of the veins. Lebert states this evolution of new 
vessels to be identical with what is perceived in other phlegmasia, and 
to be a uniform accompaniment of incipient phlebitis. The color of the 
lining membrane fades at the margin of the inflamed portion into the 
pale, healthy tissue, and itself presents various subsequent modifications 
of tint, becoming more or less mottled, violet, or fawn-colored. An 
exudation of serum is next perceived in the coats of the vein; they 
become thickened, so that when cut across the vessel may remain patu- 
lous like an artery. A deposit of fibrin in the channel of the vein 
follows, and it will depend upon the character of the deposit, and this 
in its turn upon the constitution of the individual, whether it suffices to 

1 Physiologie Patliologique, vol. i. p. 272. 

23 



354 



THE VEINS. 



Fig. 169. 



arrest the disease and render it a mere local affection, or whether it 
becomes a fresh source of contamination. The more intense the phlo- 
gistic process, the more thoroughly we shall find it affecting the coats 
of the vessel, so that the latter, as Gendrin observes, may appear to 
form a dark red cord surrounded by and closely adherent to a friable, 
red cellular sheath filled with bloody serosity, and intimately attached 
to the surrounding tissues. Gendrin has demonstrated that the lining 
membrane of veins possesses the same power of exuding lymph into 
their cavity as that of arteries; we must not, therefore, look upon the 
coagula found in the veins in phlebitis as resulting solely from a chemi- 
cal elimination of the contained blood. Lebert describes the adhesive 
fibrinous exudation as being effected by the new-formed capillaries 
between the coats, but he regards it as the rarer issue of phlebitis, 
while he attributes its very fatal character to the prevalent suppurative 
character of the disease. 

It is probable that the first effect of phlebitis is to cause the forma- 
tion of a layer of exudation matter on the lining membrane, and that 
this in its turn gives rise to the deposit of further 
coagula from the blood ; the concentric lamination 
which may generally be traced in the plug, and 
the firmer connection between it and the vessel in 
phlebitis, than in those cases of spontaneous coagu- 
lation of the blood from other causes, confirm this 
view. The coagulum itself may extend considera- 
bly beyond the primary seat of inflammation, and 
it terminates in a conical point; the plug generally 
reaches as far as the next main vessel with which 
the inflamed vein communicates, while the smaller 
branches, which contribute to its formation, become 
choked with lymph. A cure may take place at this 
stage, either by a permanent obliteration and con- 
traction of the vein, as we see in favorable cases 
of operations for varicose veins, or by a disappear- 
ance of the coagulum and a restoration of the vessel 
to its normal condition. Hasse was fortunate 
enough to experience this event in his own person, 
after the whole system of the saphena up to its 
junction with the crural vein had become blocked 
up ; he attributes the dispersion of the lymph not 
so much to absorption as to its resolution and lique- 
faction, an opinion which is rendered probable by 
the position of the deposit as well as by the absence 
of chemical changes which render it hostile to the 
vital powers. 

This, however, is not the usual termination of 
phlebitis, which more commonly leads to a suppuration of the clot, and 
secondary phenomena of the most destructive character, resulting from 
this process. In this case, a soft, straw-colored spot forms in the centre 
of the coagulum, the lamination of the latter disappears, until the whole 
is converted into a grumous mass. When portions of this mass are pro- 



Pibrinous Phlebitis. a. 
The femoral vein, occluded 
by solidified contents. At b, 
the saphena enters; and 
consolidation ends abruptly 
there. 



THE VEINS. 355 

pelled into the circulation, the symptoms of poisoning result, and we 
find the individual particles of the morbid product occasioning coagula- 
tion of the blood, or the formation of abscesses at distant points. 
Coagula resulting from this cause are most commonly met with in the 
right side of the heart, and in the distribution of the pulmonary arteries. 
They are laminated, and are softened in the interior, where there may 
be a nucleus of pus. The introduction of pus into the circulation is 
generally accompanied with symptoms of a general prostration of the 
powers, of the most intense character, which are due rather to the in- 
fection of the blood, or pyaemia, than to the local results in the shape 
of lobular abscesses, or secondary purulent deposits in distant viscera. 
Cruveilhier is of opinion that, after the occurrence of suppuration, what 
he terms a sequestration of the pus may take place, and prevent the 
general infection, by the formation of fresh coagula in advance of the 
point of suppuration, in consequence of which the pus may be absorbed 
or be discharged externally, in the shape of an abscess. 

Authors of our own country were the first to trace the connection 
between secondary deposits and local injuries. Morgagni and Desault 
had particularly alluded to abscesses in the liver following cerebral 
lesions, but it was reserved for Arnott 1 and Davis 2 to show the actual 
physical connection between these occurrences, and to establish the real 
nature of phlebitis. The latter was the first to demonstrate that it is 
the pathological phenomenon constituting phlegmasia alba dolens, a 
malady accompanying the puerperal state, which had previously been 
attributed to a reflux of the lochia, to milk depots, or to obstruction 
of the lymphatics. He showed, by a post-mortem examination of four 
fatal cases, that it resulted from inflammation of one or more of the 
principal veins within, and in the immediate neighborhood of the pelvis, 
producing an increased thickness in their coats, the formation of false 
membranes on their internal surface, a gradual coagulation of their con- 
tents, and occasionally a destructive suppuration of their whole texture. 
Dr. Graves, 3 though he admits that the veins are involved in this dis- 
ease, looks upon their inflammation as secondary to a general inflam- 
mation of the tissues, produced by a morbid impression made on the 
ultimate ramifications of the sentient nerves of the extremity ; on the 
other hand, Gendrin considers the swelling accompanying phlegmasia 
dolens to be a mere accidental concomitant of the phlebitis. Many 
cases of puerperal fever are mainly due to phlebitis of the uterus, and 
secondary inflammations induced by the former. This appears to have 
been more particularly the case with the frightful endemic of puerperal 
fever, which used, until very recently, to rage in the great hospital of 
Vienna. Dr. Semelweiss made the discovery that it mainly was due to 
the introduction of poisonous matter into the vagina and uterus of par- 
turient women, by the medical men and students, who had recently been 
handling post-mortem specimens. The proper precautions that have 
since been adopted have almost banished the disease. 4 Thus, while in 

1 Medico-Chir. Trans., vol. xv. p. 1. 2 Ibid., vol. xii. p. 419. 

3 Clinical Lectures, &c, vol. ii. p. 290. 

4 See Dr. Routh on the Endemic Puerperal Fever at Vienna, Med-Chir. Trans., vol. 
xxxii. p. 27. 



356 THE VEINS. 

1846 there were 459 deaths among 3354 females, in 1848, after the 
employment of chlorinated solutions by the medical attendants for their 
own purification, had been introduced, the deaths in 3356 patients had 
sunk to the comparatively small number of 45. In many cases of 
phlebitis resulting from venesection, the effect has been traced to a 
similar cause, viz : the introduction of poisonous matter into the vessel, 
either by the lancet, or by the use of foul sponges. It was from its 
occurrence after phlebotomy that the attention of John Hunter was first 
drawn to the subject. 

For a long time the liver was supposed to be the only organ in which 
metastatic abscesses, as secondary deposits used to be called, were found, 
and then only in connection with injuries of the brain. It was first 
shown by Arnott that no organ of the body is exempt from this lesion, 
though it occurs more frequently in the liver and the lungs, and next 
in order in the kidneys, the spleen, the heart, and superficial tissues, 
while it is met with but rarely in the brain and the cavities of the eye. 
The abscesses vary in number, but when found in one organ, we may 
expect to find them in others also, and it is rare to meet with a solitary 
secondary deposit. Thus, in a case that occurred at St. Mary's Hos- 
pital, in a boy, in whom crural phlebitis was brought on by an acci- 
dental contusion, and death occurred within six days of the injury, and 
three of the occurrence of any alarming symptoms, secondary deposits 
were found in the lungs, the heart, and the kidneys. Velpeau 1 relates 
the case of an individual, in whom, from fifteen to twenty abscesses were 
counted in the brain, from eight to ten in the lung, and purulent depo- 
sits were also found in the kidneys, the spleen, and the liver. 

We find the law of symmetry prevailing in the present as in other 
diseases ; thus in the viscera, as well as in the superficial tissues, ab- 
scesses, resulting from phlebitis, are constantly met with, at points most 
closely corresponding with one another on the two sides of the body. 

The introduction of a deleterious agent from without is not the sole 
cause of phlebitis, nor is absorption of pus necessarily followed by the 
serious consequences to which we have adverted ; we must, therefore, 
assume, that in those cases in which it occurs, there is a predisposition 
determined by a cachetic condition in the blood, to which it is attribut- 
able. Rokitansky treats of a definite form of phlebitis, depending on 
coagulation of the blood, in which the coagulation within the vessel is 
the primary phenomenon, whilst the inflammation of its coats is merely 
a secondary affection. When the coagulum is once formed, which may 
take place at different points and at different distances from the centres 
of infection, the inflammation of the coats follows. To this class we 
must refer cases of phlebitis recorded as having supervened upon invete- 
rate lues, or varioloid disease, 2 or upon catarrhal or rheumatic affections. 

In addition to the cases of inflammation of individual veins, already 
treated of, there are others to which it is right that we should especially 
advert. An inflammation of the umbilical vein in infants is mentioned 
by Kiwisch, 3 as occurring almost epidemically ; and Dr. Lee has also 

» Revue Medic, vol. x. p. 442, 1826. 

2 See Puchelt, das Venensystem, vol. ii. 88, 1843. 

3 Die Krankheiteu der Wochnerinnen, Prag. 1840, vol. i. p. 112. 



THE VEIN'S. 857 

met with it coincidentlj with the epidemic occurrence of metro-phlebitis. 
The affection generally commences between the second and fourth days, 
and is followed by peritonitis and icterus. In the adult, we meet with 
inflammation of the vena portse, which may occur idiopathically, or by 
extension of inflammation from the mesenteric veins. It has been seen 
resulting from a fish-bone penetrating through the coats of the stomach, 
into the superior mesenteric ; and the cases in which no such lesion 
could be discovered have been set down to metastatic irritation, to the 
irritation produced by spirituous beverages, suppressed hemorrhoids, 
gout, or erysipelas. The occurrence is marked by the appearance of 
what exactly resembles the formation of numerous abscesses in the sub- 
stance of the liver, but which, on close examination, prove to be accu- 
mulations of pus in the branches of the vena portse. The cases of this 
disease that are recorded are so few that we are induced to quote the 
following instance, which fell under our own observation ; it is the more 
remarkable as it presents the only instance of apparently idiopathic 
ulceration of the trunk of the vena portse, that has been published. It 
occurred in John Wright, 1 a laboring man, a patient of Dr. Alderson's, 
at St. Mary's Hospital, who, seventeen days previous to admission, was 
seized with a shivering fit ; since then he had suffered from rigor, fol- 
lowed by heats and perspirations at irregular intervals. On the 1st of 
October, 1852, a fortnight after admission, the skin is first reported to 
have been somewhat jaundiced, the pulse eighty-eight, tongue coated, 
loss of appetite, a burning sensation at the top of the sternum, with 
great depression of spirits. The yellow tinge of the skin continued, 
and the fits were fewer in number. On the 11th, the dulness of the 
hepatic region was found increased, and the stools are noted to have 
been dark. On the 18th, the skin was less yellow, the percussion of 
stomach and colon was tympanitic — no pain — no increase in the hepatic 

Fig. 170. 




Section of liver exhibiting the appearances presented in inflammation of the Vena Porte. 

dulness. The shivering fits now returned more frequently, pleuritic 
symptoms supervened, the patient became more and more weak, more 
jaundiced, and drowsy, and sank on the 24th of October, 1852. In the 

1 The case is abridged from the Records of St. Mary's Hospital. 



358 THE VEINS. 

thorax, the deposit of fresh lymph on the lower edge of the right lung, 
was all the evidence of recent disease to be found. The lungs, the 
heart, are noted as being healthy, so also the kidneys and the brain. 
The liver was found much enlarged and dark colored, feeling soft at 
many points ; on removing it from the body, about two or three ounces 
of purulent matter escaped from the portal vein ; the organ, at the same 
time, shrinking under the hand. On incising the liver, numerous bright 
yellow circumscribed spots appeared, closely resembling abscesses : they 
varied in size from a pin's head to a walnut. They proved to be all 
connected, occupying the ramifications of the portal vein, gorged with 
pus, of a perfectly laudable appearance. On examining the portal vein, 
it presented close to the point at which the spleen and superior mesen- 
teric met, a puckered, ulcerated appearance of its inner surface, extend- 
ing for about an inch towards the liver ; the ulceration w T as found to 
have penetrated through the inner coat, the edge of which was turned 
up, and well defined towards the healthy part of the vein. The ducts 
and the hepatic vein were found healthy, as also the orifices of the me- 
senteric and splenic veins. The surface of some of the portal branches 
was smooth, and these only seemed implicated as receptacles for the pus, 
while, in others, the lining membrane was destroyed, and a pyogenic 
layer substituted. The hepatic cells proved everywhere natural, the 
lobules were loaded with yellow pigment in the middle, and there was 
marked hepatic venous congestion, which it may be observed, closely 
resembled congestion of the inter-lobular plexuses. Mr. Blyth, who 
analyzed the organ, found it to contain neither sugar nor cholic acid, 
nor did the bile obtained from the" gall-bladder contain either of these 
constituents ; it follows, that the pigment in the hepatic cells was not 
biliary matter. The intestines were only partially examined, but so far 
appeared healthy. This case contradicts the assertion of Rokitansky, 
that inflammation of the vena portse invariably induces purulent and 
ichorous abscesses in the liver, and abscesses in the lung, with a very 
highly developed pyemia. No abscess was discovered either in the 
hepatic or pulmonary tissue, nor was there any evidence of pyaemia ; 
the suppuration was limited, in the most remarkable manner, to the 
trunk and branches of the vena portse. 

In the cranium, we meet with inflammation and suppuration of the 
sinuses of the dura mater as a consequence of direct injury, and not 
unfrequently as a result of otorrhoea and caries of the fibrous portion of 
mastoid cells of the temporal bone. Cerebral phlebitis is necessarily 
commonly associated with meningeal inflammation. It appears that the 
sinuses of the dura mater are liable to a chronic form of inflammation 
in children, leading to their obliteration and conversion into fibrous cords. 
Such a condition has been found by Tonnelle, and by Gintrac, in cases 
marked by symptoms of cerebral congestion and apoplexy. The latter 
author 1 gives the following case in illustration of this condition : a child, 
aged four years, was liable from its birth to a temporary suspension of 
voluntary movement. There were no premonitory symptoms, and the 

1 Recueil d'Observations, Bordeaux, 1830. Quoted by Andral, Clinique Medicale, torn, 
v. p. 266. 



DILATATION OF VEINS. 359 

attack occurred equally in the erect and recumbent position ; the intel- 
lectual faculties were maintained, but the power of articulation was 
suspended. The child died of pneumonia, supervening upon variola. 
The post-mortem examination exhibited the superior longitudinal sinus 
converted into a hard cord, the veins in connection with which were 
filled with coagulated blood. The walls of the sinus were thickened, 
dense, and of a yellowish color; it contained a solid clot; no further 
lesion was discovered in the cranium. 

Among the local cases of phlebitis not followed by general infection 
of the blood, those of the hemorrhoidal veins are the most frequent, 
though it is a complication much to be feared in all operative proceedings 
directed to their cure, as well as to that of varicose veins of the legs or 
spermatic cord. 

Rupture of the large veins is an event very rarely met with ; Haller 1 
quotes a case of rupture of the vena cava inferior, attributed to eating 
ice; but most of the instances recorded 2 were brought on by mechanical 
injury. The rupture of smaller veins often occurs as a result of sudden 
and forced distension. Thus, small ecchymoses are frequently brought 
on in the conjunctiva by violent coughing. The veins of the lower ex- 
tremities have been found ruptured by spasm of the muscles of the calves. 
The hemorrhage that constitutes epistaxis, the menstrual and hemor- 
rhoidal discharges, is rather analogous to the process of exosmosis than 
a result of actual rupture, and therefore is rather more immediately 
connected with the capillary than the venous circulation. A spontaneous 
rupture of larger veins occasionally results as a secondary consequence 
of varices. The sanguineous tumors in the labia of pregnant and par- 
turient women, are attributable to this cause, as also the laceration of 
varicose veins of the extremities, with or without coincident ulceration. 



DILATATION OF VEINS. 

Dilatation or varicosity of the veins is a subject which has attracted 
the attention of pathologists from the days of Hippocrates, who already 
distinguished between two kinds, which he termed hsemorrhois and cirsus. 

The affection is also treated of by writers under the generic term of 
phlebectasis. It consists mainly in an enlargement of the caliber of 
the vessels, and may or may not be accompanied by an alteration in 
their coats. Briquet 3 avails himself of these differences for establishing 
his classification. He assumes three varieties — simple dilatation ; uniform 
dilatation, accompanied by thickening of the coats ; and irregular dilata- 
tion, with thickening or attenuation. The distension is generally owing 
to some impediment being offered to the return of the blood to the heart; 
and we therefore most commonly meet with it in parts in which the 
surrounding tissues are lax, and consequently do not offer a sufficient 

1 Elementa Physiol, vol. i. p. 130. 

2 James Kennedy has collected all the known cases of rupture of the vena cava inferior, 
in London Medical Repository, vol. xx. 1823. 

3 Histoire des Inflammations, vol. ii. p. 9, seq. 



360 



DILATATION OF VEINS. 



resistance to the pressure of the blood. Hence, varicose veins are most 
commonly met with in the vicinity of the rectum and pudenda, and in 
the lower extremities. The veins swell, and assume a nodulated appear- 
ance and tortuous course, while the increased local pressure gives rise 

to an hypertrophy of the coats. 
Fig. 171. Gendrin 1 and Briquet attribute the 

latter to chronic inflammation. A 
necessary consequenee of the dila- 
tation is an insufficiency of the 
valves, which no longer close the 
passage to the regurgitating current. 
They suffer a solution of continuity, 
and may become partially or wholly 
obliterated. The occurrence of 
phlebectasis is connected with a 
peculiar constitution, which Hasse 
terms a morbid predominance of the 
venous system, a venous habit of 
the body, which may be character- 
ized as one of general laxity of fibre 
and want of bone, associated with 
a tendency to local congestions. 
Age exercises a marked influence 
upon the occurrence and prevalence 
of the affection. It rarely manifests 
itself in any form until puberty, and 
is most common during the prime 
of life, as the tendency to it gra- 
dually ceases with advancing years. 
An hereditary predisposition may 
very frequently be traced. There 
is also a marked difference in the 
two sexes in regard to their pro- 
clivity to certain forms of the dis- 
ease. Thus, the hemorrhoidal form 
is peculiarly an affection of the male sex, and its symptoms in many 
instances induce an impression that it is an analogue to the menstrual 
secretion in the female, from the periodicity of its occurrence, and the 
relief the flux affords to the system. In some rare cases, recorded as 
curiosities by various authors, 2 a dilatation of the large veins in the 
cavities of the trunk has been observed. We must content ourselves 
with alluding to the fact, and pass to the consideration of the ordinary 
forms of the disease. 

Varicocele, or cirsocele, affects the male sex commonly at the com- 
mencement of puberty. It consists in a dilatation of the veins of the 
spermatic cord, and prevails more on the left than the right side — a 
circumstance attributed to the more circuitous route taken by the left 

1 Archives Ge"nerales de Medecine, vol. vii. p. 200 and 396. 
a See Puchelt das Venensystem, vol. ii. p. 378, et seq. 




Varix of the veins of the 



DILATATION OF VEINS. 361 

than the right spermatic vein. How rarely it affects the right side is 
shown by the fact that, in one hundred and twenty cases operated upon 
by Breschet, all but one occurred on the left. It is important, on ac- 
count of the atrophy of the testicle, which it is likely to induce, from its 
causing hasmatocle, by hemorrhage into the tunica vaginalis, and from 
the influence which, in common with all sexual diseases, it exerts on the 
mind of the patient. The form of varicosity in the female sex, corre- 
sponding to varicocele in man, is enlargement of the vaginal and pudendal 
veins, which, especially during the advanced periods of pregnancy, are 
the cause of much suffering, and may, during labor, give rise to very 
severe hemorrhage. 

Haemorrhoids, or piles, consist in an enlargement and varicose con- 
dition of the veins surrounding the anus, and may occur in terminal 
branches of the inferior mesenteric, a tributary of the portal vein, or of 
the internal iliac. They protrude in the form of bluish nodes, or form 
flat sessile tumors. From their position, and the frequent pressure and 
congestion they are subject to when once formed, they are liable to 
inflammatory attacks ; in consequence of which the surrounding cellular 
tissue condenses and hardens. Small cysts are formed in the latter, 
into which blood is effused, and they then exhibit a complex structure, 
which has been the source of much disputation. Abernethy and Kirby 
have even gone so far as to deny that they were owing to varicosity of 
the veins, and have asserted them to be mere sacculated prolongations 
of the condensed submucous tissue. The sequelae to which they give 
rise are hemorrhage, ulceration, and prolapsus of the rectum. The 
periodical character that is often observed in the sanguineous flow, is 
one that peculiarly deserves the attention of the physician. In man 
the affliction is common in persons of the middle of life, who have fol- 
lowed a sedentary pursuit ; in women they are more apt to occur during 
pregnancy, and as a substitute for the menstrual discharge at the period 
of the climacteric. 

Of all forms of varix, none is, probably, of so frequent occurrence as 
that which affects the superficial veins of the lower extremities, and more 
particularly the ramifications of the saphena. It is not peculiar to either 
sex, but is decidedly more common in females than males. This remark 
does not appear to apply to the continent, however, for we learn from 
the statistics of Briquet, as well as from the statements of Hasse, that, 
with them, the male sex is the most liable. Another statement of Bri- 
quet's, that it is more frequent in the right than in the left leg, is not 
confirmed by British experience. Hasse observes that, in men, the 
dilatation generally arises from the trunk, or the principal branches of 
the saphena, while he states that, in women, it commences in the minute 
twigs. It is especially at the ankle, and at the inner side of the popliteal 
space, that the veins are seen and felt, in the shape of an accumulation 
of tortuous vessels, of a more or less resistant feel. 

A varicose state of the veins of the pia mater is a condition upon 
which Rokitansky lays some stress, as found after repeated attacks of 
delirium tremens. Oculists treat of dilatation of the veins of the eye 
in various forms ; and instances of varix in other parts of the upper half 



362 DILATATION OF VEINS. 

of the body are recorded by authors. Thus, Cruveilhier 1 delineates two 
cases of varix affecting the arm. 

Varicose veins may prove dangerous, by giving rise to hemorrhage, 
in consequence of ulceration or rupture. They are not, like the arteries, 
subject to atheromatous disease, though occasionally they become ob- 
literated by the formation of a coagulum, or spontaneous inflammation 
and cohesion of the parietes. 

An obliteration of portions of the venous system, from spontaneous 
coagulation of the blood during life, is a not unfrequent occurrence, 
either from the pressure exerted by morbid growths, as aneurisms or 
cancerous tumors, or without such mechanical causes, from sheer cachectic 
debility, as, for instance, in a case of empyema that fell under our notice, 
in which, from the inferior cava downwards, the veins were plugged up 
with a fawn-colored coagulum. They are not, however, limited to the 
veins of the inferior half of the body, though most frequently met with 
in the vena cava inferior, and the portal vein. Dr. Bright 2 records a 
case in which the longitudinal sinus was filled in a child of twenty 
months, another of a female aged seventeen, in whom the left jugular 
and subclavian veins were plugged with a firm coagulum, terminating 
abruptly just as they entered the cava, and a third, in a female aged 
twenty, in whom a white, fibrinous coagulum was found in the subclavian 
vein, extending two or three inches up the jugulars. In both the last 
cases the hardened veins were traced during life ; the subjects were all 
in an extreme state of exhaustion. In these cases, the coagulum can be 
easily removed from the channel of the vessel, and the coats of the latter 
present no evidence of inflammation in the shape of thickening or inter- 
stitial deposit, or roughening of the lining membrane. Another form 
of obliteration is that resulting from a chronic inflammation and conse- 
quent adhesive process, set up by the advance of degenerative disease, 
such as tubercle or cancer. Thus Dr. Lee records two cases of abdo- 
minal phlebitis resulting from malignant disease of the uterus ; and 
another of inflammation of the iliac veins in a man, from carcinoma, is 
related by Mr. Lawrence. Tubercle never directly affects the vessels ; 
it is not found deposited in the coats, nor is it found in their channels. 
Carcinomatous matter, on the other hand, is very frequently discovered 
within the veins, either as an immediate extension of the disease, external 
to them, or as an absorption of the morbid product. Thus, in cancer of 
the stomach and liver, it has been found in the vena portse; in renal 
cancer, in the corresponding vein and the vena cava inferior ; in uterine 
cancer, in the vena cava and its branches. Few of the observers of the 
cases on record have verified the fact of the cancerous nature of the 
contents of the vessels by microscopic examination, and in many instances 
fibrinous coagula have been mistaken for cancer, when coincident with 
the latter. Langenbeck 3 has, however, established the possibility of the 
occurrence of cancer within the vessels, by observing cancer-cells in the 
blood of individuals affected with malignant disease of the uterus. We 

1 Anatomie Pathologique, Livr. xxiii. and Livr. xxx. 

2 Medical Reports, p. ii. pp. 60, 64, 65. 

3 Essai sur 1' Anatomie Pathologique. Par. 1816, vol. ii. p. 70. 



ENTOZOA. 



363 




must not, however, regard the presence of any one variety of cell as 
essential to determine the malignant character of a morbid growth. 
The inherent tendency of a certain blastema or matrix is to lead to the 
production of appearances which are commonly denoted as tubercle, or 
as cancer, but that blastema in itself need not present any microscopic 
signs to distinguish it from healthy albuminous or fibrinous deposits. 
Hence it is not absolutely necessary that we should meet with what are 
commonly called cancer-cells in the cancerous contents 
of the veins, in order to justify the conclusion as to their 
malignant character. Ossification very rarely affects the 
veins, but cretaceous deposits are occasionally discovered 
under the lining coat, as in the case of which we have 
given a delineation. Cruveilhier 1 relates the case of an 
old man who died of gangrena senilis, in whom the veins 
accompanying the popliteal artery were studded with 
phosphatic deposit. This must not, however, be con- 
founded with that variety of concretions termed vein- 
stones, or phlebolithes, which are met with free in the 
cavity of the vessels. These are formed of concentric 
laminae, of which the internal are hard and brittle, while 
those forming the outer layers present a softer consist- 
ency. They closely resemble the concentric corpuscles 
so frequently met with in the choroid plexus, where, how- 
ever, the formation is external to the vein. They are found most fre- 
quently in the pelvic veins, and in varices, and appear to result from a 
stasis in the blood, first giving rise to a coagulum of fibrin, within which 
a process of cretification takes place ; chemically they are found to con- 
sist of phosphate and carbonate of lime, bound together by animal 
matter. The theory of their formation agrees with the mode of expla- 
nation which suggests itself for other concentric corpuscles, and is con- 
firmed by what we occasionally see in diseases. Thus, in a case of a 
large cyst in the kidney, containing, within an inner sac of false mem- 
brane, a large black coagulum of blood, we found concentric corpuscles 
in the false membrane, of exactly the same character as those observed 
in the brain. Here, too, it seemed reasonable to assume the primary 
deposition of fibrin, and the secondary precipitation within its laminae 
of the phosphate of lime. It is not impossible that phlebolithes may 
in some instances be the residuary traces of former phlebitis. Dr. Lee 
observes, 2 that in the spermatic and hypogastric veins of females ad- 
vanced in life, calcareous concretions and disorganizations of various 
kinds have frequently been observed, which must have been the conse- 
quence of attacks of acute inflammation at remote periods. 



Calcareous deposit 
in the coats of a Tein. 
— St. George's 3Iu" 
seum, F. a. 12. 



ENTOZOA 



Before quitting the pathology of the veins, we have to allude to the 
presence of entozoa, and of gaseous contents within them. Of the 



Medico-Chirurgical Transactions, vol. svi. p. 418. 



2 Ibid. 



361 AIR IN THE VEINS. 

former, instances are recorded by various of the older authors, from 
Pliny the elder downwards. This writer states, in his Historia Natu- 
ralis, that animals form in the blood of man, and destroy his body. The 
most recent observation of parasitic animals in the blood is recorded by 
Dr. Bushman; 1 but it is liable to objections which tend to invalidate the 
conclusions arrived at. The observation of the presence of distoma 
hepaticum in the trunk of the vena portae in a man aged forty-nine, by 
Duval, 2 is more valuable and trustworthy. Andral 3 recounts the only 
instance known of hydatids found in the venous system. They occurred 
in the pulmonary veins of a man aged fifty-five, and twenty-three occu- 
pied the small ramifications shortly before their transition into the 
capillary network. They varied in size from a pea to a nut, and were 
symmetrically distributed through both lungs. They had all the cha- 
racters of acephalocysts. 



AIR IN THE VEINS. 

The entrance of air into the veins is one of the most formidable 
occurrences complicating operations about the neck, that the surgeon 
has to deal with. Death ensues rapidly, and atmospheric air is found 
in the right side of the heart. Air has been traced in some of these 
cases in the aorta, the crural arteries, the arteries of the brain, the in- 
ferior cava, the iliac veins, and the coronary veins of the heart. 4 It has 
been suggested that, in some cases of sudden death after delivery, the 
cause might be found in an introduction of air into the circulation by 
the open mouths of the veins, when the uterus contracted imperfectly. 
Another question is the possibility of the spontaneous evolution of gas 
within the veins during life. Many of the cases on record are undoubt- 
edly mere instances of rapid putrefaction; but we are justified both by 
the constitution of healthy blood, and by post-mortem observation, in 
admitting the reality of such a change before death. Numerous authors, 
among whom we would mention Dr. Baillie, 5 have met with air in the 
veins of the pia mater in cases of apoplexy, before any traces of decom- 
position were to be perceived. Dr. Bright 6 attributes the presence of 
air in these cases exclusively to accidental injury of the veins, or to in- 
sipient putrefaction. The evolution of gas during life, though difficult 
of absolute proof, is entirely within the range of probability, when we 
consider that venous blood contains an excess of carbonic acid gas, which 
is discharged on reducing the atmospheric pressure, as demonstrated by 
Magnus. "Perhaps," as Professor Puchelt remarks, ■" it happens more 
frequently than we are aware, that a bubble of air forms in the venous 
blood, and again disappears. I am acquainted with at least one variety 
of palpitation, which produces the sensation ; and, I am almost inclined 

1 The History of a Case in which Animals were found in Blood drawn from the Veins 
of a Boy, London, 1833. 

2 Gazette M&licale de Paris, 1842, No. 49. 

3 Magendie, Journal de Physiologie, vol. iii. 69. 

4 See Puchelt, das Venensystem, Liefing, 1843, vol. iii. p. 328. 
6 Morbid Anatomy, p. 430. 

6 Medical Reports, vol. ii. p. 668. 



THE CAPILLARIES. 365 

to assert, the noise, as if a bubble passed through a fluid. It occurs 
generally with but one beat of the heart, and I have met with it in 
venous subjects with an hemorrhoidal tendency, and a liability to flatu- 
lency." 

THE CAPILLARIES. 

The importance of the capillary circulation in its bearings upon dis- 
ease, and the relation borne by the blood to the coat of the vessels, and 
by both to the nervous terminations and other surrounding tissues, can 
scarcely be over-estimated; and yet we are inclined to think that in 
most of the experiments performed with a view to determining their 
functions or ascertaining the part they bear in disease, as in inflamma- 
tion, the most important of all morbid processes, the share taken by the 
vessels has been regarded more than the changes occurring in the circu- 
lating medium itself. A great physical difficulty presents itself in the 
examination of the ultimate radicles of the vascular system in most of 
the organs of the body, from our inability sufficiently to isolate them. 
Where we are able to do so, as in the brain or pia mater, we may, in 
inflammation, trace the evolution of the morbid product in the shape of 
minute molecular spherules, but the coats of the vessels must be looked 
upon rather as the passive agents of percolation, than as the active pro- 
moters of the diseased action. Calcareous deposits are also seen, as in 
cases of cerebral apoplexy, upon very minute vessels, but we do not 
possess any means of determining in how far the vascular coats are 
liable to anything like an idiopathic morbid condition. We need not 
enter into the question of the part played by the capillaries in nutrition 
and inflammation, as that is discussed in the general pathology. There 
are few morbid processes in which they are not involved, though at the 
same time we must not forget that they are not essential to diseased 
action, and that, as many healthy changes of the body are affected by 
metamorphoses directly from the blood, or through the intervention of 
non-vascular tissue, so, in disease, the capillary system is one of several 
Of the agents of the morbific influence. We must here allude to a form 
of inflammation which, from presenting somewhat peculiar characters, 
has been termed by Cruveilhier, capillary phlebitis. It depends upon 
the same causes as those to which we have traced metastatic abscesses, 
or purulent deposits, viz: a poisonous infection of the blood, and hence 
is most commonly met with in organs to which there is a great afflux of 
blood, as in the lungs, the spleen, the kidneys, and the liver. The form 
in which it appears, is that of a circumscribed patch of injected and in- 
flamed tissue, which, by itself, may pass through the various stages of 
inflammation; or it may, in its turn, excite active inflammation in the 
surrounding parts, which will present different features, in color and 
consistency, by which the two may be distinguished. Rokitansky ob- 
serves that capillary phlebitis is not essentially a true inflammation, but 
that it consists in a coagulation of the blood in some portion of the 
capillary system, and is analogous to the phlebitis caused by coagula- 
tion. He states that the coagulum at first appears as a dark red in- 
farctus of the affected parenchyma ; that it subsequently may undergo 



366 THE CAPILLARIES. 

various processes, either breaking up and commingling with the blood, 
or undergoing a retrograde process, leading to obliteration and atrophy 
of the part affected, or passing into purulent or gangrenous fusion. 
Rokitansky also expresses it as his opinion that the capillaries may be 
affected in a similar way as he describes the arteries to be, by an exces- 
sive deposition of "lining membrane," only that the anomaly is here 
less in degree, owing to the arterial portion of the blood being expended 
in the process of nutrition. 

Among the chronic forms of disease which are attributed more par- 
ticularly to the capillaries, and to which we have not had occasion to 
allude elsewhere, is the affection which Mr. John Bell, and English 
writers following him, have termed aneurism by anastomosis, or the 
Germans, more classically, teleangiectasis. 1 It is also known by the 
simple term, erectile tumor, which is probably the best, as it implies no 
theory. The affection is commonly congenital, and presents itself in the 
shape of a cutaneous swelling of a circumscribed form and bluish-red 
color, liable to considerable variations of distension, according to the 
state of the circulation. The tumor commonly, though not always, offers 
a pulsation to the touch isochronous with the arterial pulse. Bell described 
the tumor as consisting of a congeries of vessels, between which were 
cavities and cells communicating with the latter; others have attributed 
the affection solely to a distended condition of the vessels, among whom 
may be mentioned Syme and Pelletan ; it is, however, extremely pro- 
bable that both conditions may occur, as in the analogous case of hemor- 
rhoidal tumors ; and that while one erectile tumor contains only vessels, 
another consists of both vessels and cellular cavities. This explanation 
would aid in understanding the difference in the symptoms presented by 
this species of tumor. 

1 Teleangiectasis — literally, expansion of the remote vessels; ?«Xe, distant, remote; 
ayyos, a vessel ; extwww, I distend. See also page 175. 



CHAPTER XXV. 

THE LYMPHATIC SYSTEM. 

Our knowledge of the diseases of the lymphatic system is not com- 
mensurate with the importance we attribute to it in the animal economy 
on physiological grounds. We may infer, from the close relation which 
it bears to the metamorphoses of the tissues, that it must be morbidly 
affected in all diseased conditions of individual parts, while its anatomi- 
cal bearings assist in accounting for the difference which prevails between 
diseases specially affecting the lymphatic vessels and the veins. A morbid 
product, or a poison that has found its way into a vein, meets with no 
impediment, and, unless adhesive inflammation be set up at the point of 
introduction, speedily taints the whole system ; the force and direction 
of the blood-current materially facilitate the propulsion of any foreign 
matter that has entered the vein. In the lymphatic vessel we have no 
such powerful and continuous stream, nor do the channels enlarge in the 
same uniform manner as in the former ; on the contrary, we find the 
passage every now and then blocked up by a sluice, in the shape of a 
lymphatic gland, the obvious object of which is to submit the contents 
of the afferent vessel to a process of purification. By this means, fur- 
ther security is provided against the ultimate introduction into the blood, 
by the thoracic duct, of deleterious matter, which may have penetrated 
the lymphatics. Hasse 1 observes that the lymphatic vessels, being ex- 
clusively devoted to the purposes of absorption, can contain fluids of 
very various, and even morbid admixture, without detriment to their 
internal membrane, and that it is not until the fluids in question have 
reached the lymphatic glands that inflammatory reaction becomes esta- 
blished. He instances the conveyance of miasmatic and contagious 
matter through the lymphatic system, as in typhus, the plague, &c, 
where the lymphatic vessels never exhibit any morbid alteration, although 
the glands are found more or less disorganized. We must, however, 
demur both to the fact and to the conclusions drawn by Hasse ; for 
although undoubtedly the mere presence of noxious matters, either in 
the blood or in the lymph, does not necessitate inflammatory reaction in 
the coats of the vessels, the fact of lymphatics presenting all the symp- 
toms of inflammation between the seat of irritation and the next chain 
of glands is one of too frequent occurrence to establish it as a rule that 
the morbid manifestation only takes place in the latter. The metamor- 
phosing and eliminating power of the lymphatic glands is one that exerts 

1 An Anatomical Description, &c, Sydenham Society's Ed. p. 2. 



363 THE LYMPHATIC SYSTEM. 

a most important influence upon the preservation of health, and, where 
it is weakened, as in scrofulous individuals, we see that every species of 
disease makes an easy ingress, and is with difficulty expelled. This 
circumstance offers a satisfactory explanation for the great variation in 
the susceptibility of different individuals to the action of morbid agents; 
as we see in the undoubted exposure of several subjects to the same 
infectant ; when, for instance, the same venereal female receives a suc- 
cession of visitors, we have good grounds for assuming that each of the 
men came into contact with the syphilitic poison, we may find one 
enjoying an entire immunity from evil effects, while the other becomes 
the subject of secondary and tertiary symptoms. 

Inflammation of a lymphatic is manifested by redness, painfulness, 
and swelling, in its course ; the coats become thickened and infiltrated, 
and exudation and suppuration may occur in their channels. A resolu- 
tion is the most common termination of the process. The presence of 
pus in the lymphatics does not necessarily demonstrate the existence of 
inflammation of the vessels ; it may be introduced into them by abrasion 
or ulceration of lymphatics communicating with an abscess. Suppu- 
rative inflammation gives rise to small isolated abscesses along the 
course of the lymphatic vessels, forming, as it were, stations of the 
disease, each of which appears to serve as a fresh focus of morbid 
action. The inflammatory process more or less affects the surrounding 
cellular tissue from the commencement. With the advance of the in- 
flammation, the lymphatics are blended with it, and suppuration and 
the formation of abscess involve the entire mass. A chronic inflamma- 
tion of lymphatic vessels is met with in scrofulous, tubercular, and 
cancerous disease. Their coats are found indurated and thickened, 
and their channels are blocked up with the morbid blastema of the 
heterologous growth. The frequency with which this occurs, appears 
to be in a ratio to the softened condition of the deposit in the organ 
from which the affected lymphatics take their origin. Thus, in a case 
of encephaloid cancer of the stomach, in an aged female, that occurred 
under our own observation, the plexus of lymphatics occupying the 
lesser curvature of the organ were gorged to the size of crows' quills 
with the cancerous matter. 1 In the majority of instances, we meet with 
no such filling up of those vessels, and the subacute inflammation which 
coexists in their glands appears to be either the result of irritation pro- 
pagated to them from the primary seat of the lesion, or of idiopathic 
disease set up in them as the purifying agents of the blood. Sir Astley 
Cooper 2 reports three cases of obliteration of the thoracic duct, two of 
which were connected with tubercular, the third with cancerous disease. 
In the first, the obstruction was produced by the thickened valves, in 
three distinct parts, adhering to one another, the lowest still allowing of 
a partial transmission of fluid, the upper arresting it entirely. Scrofu- 
lous matter was found deposited between the laminae of the valves. In 
the second there was considerable thickening and ulceration of the duct ; 
two fungous growths occupied the channel ; and in the third, which 

1 Report of Pathological Society, 1847-48, p. 195. 

2 Medical Records and Researches, 1798, p. 87. 



THE LYMPHATIC SYSTEM. 869 

occurred in a man who had died in consequence of malignant disease of 
the testis and the lumbar glands, the thoracic duct was found much 
thickened, and filled with a pulpy mass, composed of broken, coagulable 
lymph. Opposite the curvature of the aorta, the vessel was lost in a 
swelling as large as a moderate-sized walnut, beyond which it was nor- 
mal. The paper from which these cases are derived, contains various 
experiments upon the thoracic duct in animals, of physiological interest. 
One of the main conclusions arrived at by the author in reference to 
this point is, that the circulation in the lymphatic system may be kept 
up by dilatation of collateral vessels subsequent to the occurrence of 
obstruction in a trunk, as in the vascular system at large. 

A varicose condition of lymphatics is occasionally met with in atonic 
habits, causing them to resemble hydatid tumors. It affects parts of 
the system, and especially the thoracic duct is liable to dilatation ; occa- 
sionally the entire system is found in this condition, and an extreme 
instance "of this, occurring in a young man, aged nineteen, which hap- 
pened in the practice of M. Amussat, is given in the works of Breschet 
and Carswell. Cruikshank 1 alludes to and delineates a similar case. 
Here, the lymphatics of the groins had reached a size sufficient to permit 
of the introduction of a straw by which air was blown into them ; the 
iliac ganglia had entirely disappeared, and were replaced by the lym- 
phatic vessels. A corresponding enlargement of these vessels was traced 
through the abdomen into the thorax ; none of the other viscera pre- 
sented any marked pathological changes. The depurating functions of 
the lymphatic glands while they render these organs safety-valves to 
the system, also induce in them a frequent liability to disease, which is 
characteristic of what is familiar to us as the lymphatic constitution. 
The irritation to which their affections are traceable, may proceed from 
some local lesions, from which it is carried to the neighboring glands 
by the connecting lymphatic, as in the case of a sore on the prepuce, 
inducing bubo, or of porrigo of the head, causing tumefaction of the 
cervical glands ; or, it may be excited directly by the morbid condition 
of the blood circulating in the capillaries of the glands. 

Simple acute inflammation is manifested by tumefaction, softening, 
and a highly vascularized state of the organ, causing it, on division 
with the knife, to distil blood, while its color is changed from a reddish 
gray to a dark red or crimson tint. If suppuration has ensued, yellow 
spots first appear in different parts, and eventually the entire gland may 
be destroyed by the process, and be converted into an abscess, in which 
the surrounding cellular tissue is more or less implicated. The chronic 
form is, however, the more common; a species of plastic matter is 
effused interstitially, and induces gradual enlargement and induration of 
the gland. This condition may be perpetuated, and the resulting hy- 
pertrophy exhibits a conversion of the effused matter into the ordinary 
cell structure, displayed by the microscope as constituting the gland 
tissue. On the other hand, a reabsorption of the interstitial deposit 
may occur, as we have frequent opportunities of observing, as the effect 

1 See Carswell, Patholog. Anat. Fasc. ix. pi. iv. fig. 4 ; and Breschet, Le Systeme Lym- 
phatique, 1836, p. 260. 

24 



370 THE LYMPHATIC SYSTEM. 

of a suitable dietetic and medicinal regimen, in consequence of which 
the parts regain their normal size and appearance. 

Hypertrophy of the glands, whether simple or complicated, with the 
tubercular diathesis, is peculiarly prevalent in childhood, at the time 
when the vegetative development of the animal economy makes the 
greatest claim upon the organs of nutrition and metamorphosis; an 
atrophic condition is met with in advanced age, after the period of in- 
volution has commenced, and it is stated by Rokitansky particularly to 
affect the mesenteric glands as a result of typhous infiltration, in con- 
sequence of which the parenchyma of the gland is absorbed, as well as 
the product of the process. The inflammation of the mesenteric glands 
accompanying typhous fever, is a point upon which Rokitansky 1 lays 
great stress. He considers it as an integral part of ileotyphus, and 
states it particularly to attack the chain of lymphatic glands corre- 
sponding to the affected part of the intestine. He looks upon it as a 
substantive affection of the glands, allied to the morbid condition which 
they present in the Oriental plague. The reader will see that, in regard 
to the lesions of the mesenteric glands in fever, there is a wide differ- 
ence of opinion between Rokitansky and Drs. Stewart and Jenner, who 
on very satisfactory evidence have shown that typhus and typhoid fevers 
are distinct forms of fever, one of the characteristic features of the 
latter being the intestinal ulcerations and disorganization of the mesen- 
teric glands, while no such affections are met with in typhus. 2 

TUBERCLE. 

Few parts of the body are more exposed to the deposit of tuberculous 
matter than the lymphatic glands. It occurs in them either in a pri- 
mary or secondary form, as the result of direct elimination from the 
bloodvessels, or owing to the conveyance of tubercular matter from the 
organ from which the lymphatics are derived. We see it in the shape 
of yellowish masses, interspersed among the gland tissue; and as the 
morbid deposit increases, encroaching more upon, and ultimately en- 
tirely destroying all traces of, the normal tissue. The tubercular mat- 
ter is observed to go through the same processes of softening and sup- 
puration, or of induration and cretification, that we find it liable to 
elsewhere. Children are peculiarly prone to tubercular disease of the 
glandular system ; but there is a considerable difference in the proclivity 
of different sets of glands to be affected. All authors are agreed that 
the bronchial are pre-eminently endowed with this tendency. The 
analysis of one hundred post-mortem examinations of tuberculous chil- 
dren, by Dr. Lombard, 3 showed that 

the bronchial glands were affected in 87 cases, 
the mesenteric " " 31 " 

the cervical " " 7 " 

the inguinal " " 3 " 

1 Pathological Anatomy, Sydenham Society's Edition, vol. iv. p. 390. 

2 For the further details we must refer to the original papers of these authors, which 
are contained in the Medical Times (1851) and the Edinburgh Medical and Sm-gical Jour- 
nal (1840). 

3 Andral, Pr6cis d'Anatomie Pathologique, vol. i. p. 425. 



CARCINOMA — MELANOSIS. 371 

In the case of the bronchial glands, a communication is occasionally 
established between their contents after they have softened and the 
channel of the bronchi, and may be thus evacuated, by expectoration. 
The chalky concretions find their way out occasionally in the same 
manner. A remarkable instance of death being caused by the impac- 
tion of the cretaceous contents of a bronchial gland in the bronchi, is 
detailed by Dr. Tice, in the twenty-sixth volume of the Medic o-Qhirur- 
gical Transactions. 

CARCINOMA. 

The lymphatic glands are very commonly the seat of malignant dis- 
ease; it affects them either primarily or secondarily, but more fre- 
quently in the latter form. It is probably owing to the implication of 
the lymphatic system that we may, in part, at least, attribute the symp- 
toms of cancerous cachexia in an advanced state, as influencing the 
process of nutrition and assimilation. No other part of the economy 
is so liable to secondary cancerous deposits as the lymphatic glands ; 
the immediate cause of their becoming the seat of the heterologous 
growth being the introduction of cancer blastema from the affected 
organ, or an irritation set up by the proximity of the gland to the latter, 
which, in its turn, excites a fresh separation of cancer matter from the 
blood. The second explanation is probably that which obtains in most 
cases ; for we find the parenchyma of the gland to be the prevailing 
seat of the disease, both in primary and secondary carcinoma of the 
lymphatic glands. It commonly appears in the shape of a general in- 
filtration, and rarely in isolated nodules or islets. The encephaloid or 
medullary variety is the form which carcinoma generally presents in the 
glands. In a case of pancreatic sarcoma affecting the thoracic muscles 
of the right side, which fell under our own observation, there was a 
development of a similar morbid growth in the anterior mediastinum, 
evidently involving, if not proceeding from, the bronchial glands. The 
tissue was made up of fibres and fibroid cells and circular corpuscles, 
containing oil-particles. The lungs and other viscera presented no 
trace of a similar disorganization. In another instance, occurring at 
St. Mary's Hospital, in which the bronchial glands were converted into 
a mass closely resembling a malignant growth, though the microscope 
only exhibited granular corpuscles, resembling the forms seen in tuber- 
cle, the lungs were free from substantive disease, though the spleen was 
both disorganized and hypertrophied, and presented in its tissue deposits 
resembling those found in the bronchial growth. 



MELANOSIS. 

An affection to which the glandular system, and especially those parts 
in relation to the respiratory organs, is very prone, is melanosis ; it is 
scarcely, however, to be looked upon as a morbid process in itself, but 
rather as an evidence of the depurating functions by which they assist 
in eliminating the superfluous carbon from the blood. "We have shown 



372 ENTOZOA. 

elsewhere that melanosis does not, in itself, constitute a malignant disease, 
and that it does not consist of a new formation, but that it is mainly a 
secretion of normal constituents of the blood, though frequently compli- 
cated with malignant affections. While it is unusual to find black matter 
in the lymphatic ganglia of the abdominal or inguinal regions, we con- 
stantly meet with it in the glands surrounding the bronchi. 



ENTOZOA. 

The only instance on record, of entozoa being found in the glands, is 
recorded by Rudolphi. 1 It was found by Treutler, in a person worn 
out by syphilis ; it was an inch in length, tawny in color, semitransparent 
at one end, presenting two hooklets at its anterior extremity, and hence 
termed hamularia bronchialis. 

1 Entozoorum Historia Naturalis, vol. ii. p. 82. 



THE PATHOLOGICAL ANATOMY OF THE 
ORGANS OF RESPIRATION. 



CHAPTEE XXYI. 

GENERAL OBSERVATIONS. 

"We learn from the registers of mortality that the most prevalent cause 
of death at various ages is to be found, in our climate at least, in morbid 
conditions of the organs of respiration ; if it were possible to estimate 
the amount of disease introduced into the system through the lungs, 
though manifested in other organs, we should enhance the importance 
of an intimate acquaintance with their pathology still further. While 
the lungs serve the purpose of affording to the blood the means of effect- 
ing the changes of assimilation and metamorphosis, this very function 
renders them, by their extent of surface, and by their intimate relation 
to the capillary circulation throughout the body, more than any other 
organ the portal of disease. The impalpable poisons borne on the air 
enter the human economy chiefly by this entrance, and the system, 
debilitated by the various influences that wear out its strength, is attacked 
at this point by irritants of all kinds, introduced directly from without, 
palpable and impalpable. Thus, the lungs and their accessory parts are 
subject in various ways to suffer primarily or secondarily from causes 
that scarcely affect other organs; no age is exempt; no sex or rank 
offers any immunity ; the common air is the common danger, and the 
sanitary measures necessary to anticipate or remove it, confer im- 
measurable benefits upon all, though the boon may be but scantily ac- 
knowledged. 

We shall examine the pathological conditions of the different parts of 
the respiratory system in the order in which they naturally present 
themselves, as we proceed from the orifice downwards ; commencing 
with the larynx and its appendix the epiglottis, we shall descend to the 
trachea, the bronchi and their ramifications, the pulmonary parenchyma, 
and the pleura. Though a definite relation exists between these different 
parts, which is more intimate in some than in others, they are each sus- 
ceptible of isolated morbid states ; and though the continuity of the 
mucous membrane lining the entire passages frequently induces a pro- 
pagation of disease from one part to the other, this is by no means uni- 



374 THE EPIGLOTTIS. 

versally the case, and the catarrh or croup affecting the larynx or trachea 
need not cause any pathological changes in the adjacent mucous mem- 
brane, or the other tissues of the affected part itself. The absolute 
importance of the morbid condition to the individual, does not necessa- 
rily bear a direct relation to its intensity, but depends a great deal upon 
the part affected; a point which the physiological laws regulating the 
different sections of the respiratory organs render sufficiently palpable ; 
thus, a trifling amount of inflammatory swelling of the glottis or epiglottis 
threatens danger, while much more intense inflammation of the pulmo- 
nary parenchyma, or of the bronchi, may run its course without causing 
more than a temporary inconvenience. The features of the morbid 
condition may be identical, while their bearings upon the existence of 
the individual are widely dissimilar. 



THE EPIGLOTTIS. 

The epiglottis is, notwithstanding its exposure, not very liable to dis- 
ease, a circumstance due in part to the dense fibrocartilaginous tissue 
which forms its substratum. The mucous membrane which invests it, 
may be affected with acute or chronic inflammation, in which case the 
vessels enlarge and become tortuous and congested, and the light pink 
hue is converted into a streaky, or more or less uniform redness. The 

Fig. 173. 




Acute ulceration of the epiglottis and surrounding; parts in a man, caused by taking a large dose of bichlo- 
ride of mercury. Death followed after nine days ; there were pneumonia, ulceration of the stomach, and 
inflammation of the entire intestinal tract. 

acute form is commonly the result of mechanical injury or chemical 
irritation; while the chronic form accompanies old standing catarrhs of 
advanced age, arthritic or syphilitic cachexia, and other conditions 
resulting from general atony. The former is met with as a result of 
the action of irritant poisons, which may thus cause death without pass- 



THE EPIGLOTTIS. 375 

ing the fauces ; and as Dr. Marshall Hall 1 has pointed out, in conse- 
quence of children, as frequently happens among the poorer orders, 
drinking boiling water from the spout of the kettle or tea-pot. In these 
cases there is also rapid and extensive oedema, giving rise to a mechanical 
impediment to the admission of air into the lungs. In one of the in- 
stances detailed by Dr. Davis, 2 suffocative dyspnoea supervened within 
three or four hours, and when at this period the attempt was made to 
apply leeches, the child, a little girl of three years of age, was much 
terrified, and screamed so violently, that they could not be applied. 
From this moment, however, respiration became easy, and a speedy 
recovery took place, owing most probably to a rupture of the bullae 
which had formed in consequence of the irritation. The remedy which 
in such a case relieves the immediate symptoms, and may thus be the 
means of saving life, is the operation of tracheotomy, though, as in the 
instance from which the delineation was taken, not always successful. 

Ulcerations of the epiglottis are not unfrequent, more especially as 
complications of phthisis ; they are generally limited to the inferior 
surface of the valve and to its mucous covering; though they occasion- 
ally penetrate to the fibro-cartilage. They are not generally accom- 
panied by much tumefaction or reddening of the surrounding tissue. 
Louis 3 states that in all the cases that fell under his notice, he only once 
observed ulcerations on the lingual surface ; he found the breadth of the 
ulcers to vary from about one to two lines; though in some cases the 
laryngeal surface of the epiglottis was entirely deprived of its mucous 
membrane: in four cases the edge of the fibro-cartilage was destroyed, 
as well as the surface ulcerated, so as to give the part a festooned 
appearance; in a fifth case the epiglottis was totally destroyed. The 
proportion of phthisical cases in which the epiglottis is affected, appears, 
according to the same author, to be about one-quarter. These ulcers 
are not, however, the result of a fusion of tubercular deposit, which is 
not met with at this point, but of sympathetic irritation and inflamma- 
tion; they, like other affections of the mucous membranes of the air- 
passages which have been mistaken for tubercular deposit, often originate 
in occlusion and Sebaceous enlargement of the numerous solitary follicles 
scattered about the respiratory mucous membrane. These vary in size 
from an almost imperceptible point to a pin's head, and even to that of 
a bean; 4 and closely resemble miliary granulations, surrounded by a halo 
of bloodvessels, as they appear for instance in the pia mater. The 
microscope, however, reveals their structure; showing the basement 
membrane of the follicle lined with epithelium, and containing oily mat- 
ter. The cheesy particles coughed up by many people, are formed partly 
in the follicular structures of the tonsils; and probably also in the folli- 
cles of which we have just spoken. The epiglottis is liable to suffer 
from syphilitical ulceration, by an extension of the disease from the 
fauces: it very rarely passes beyond to the larynx and trachea. In 
smallpox and other eruptive fevers, the peculiar poison of the disease 

1 Medico-Chirurgical Transactions, vol. xii. p. 1. 

2 Ibid. 

3 Researches on Phthisis, Sydenh. Soc. Ed. p. 42. 

4 See a case detailed in Dr. Bright's Reports, ii. p. 644. 



376 



THE LARYNX 



often sets up its action in the fauces and the respiratory passages ; the 
former may give rise to pustules on the glottis, accompanied by more 



Fig. 174. 



Fig. 175. 



Fig. 176. 




Fig. 174. — (Edema of the epiglottis, brought on by drinking scalding water, and causing the death of the 
child, a boy aged three years and nine months, in two hours. The uvula, which is seen a little above and to 
the right of the epiglottic, was also oedematous. No other feature was observed, except some reddening of the 
bronchial mucous membrane, and congestion of the lungs. Tracheotomy was performed. 

Fig. 175.— (Edema Glottidis. 

Fig. 176. — Acute (Edema Glottidis; exposed from behind. 

or less redness and serous infiltration; in, the latter, ulcerative destruc- 
tion and oedematous swelling occur. It is to an affection of these parts 
that more particularly the danger of the retrocession of the cutaneous 
affections is attributable : there is frequently an inverse ratio between 
the force with which the external and internal symptoms are manifested. 



THE LARYNX. 



The mucous membrane of the larynx presents the same changes that 
we meet with in the mucous membrane investing the entire respiratory 
tract. In health it has an almost colorless, slightly pink hue, and con- 
sists of a uniform epithelial surface, overlaying a basement membrane, 
underneath which the vascular network ramifies. The surface is broken 
only by the minute follicles which open upon it. In congestive and in- 
flammatory states this vascular network becomes much distended ; the 
membrane is rendered thick and soft by mere repletion in the first 
instance, and subsequently by interstitial effusion. The more lasting 
and chronic the inflammatory action, the more this thickened condition 
is established, and thus a permanent hypertrophy of the membrane is 
effected. The color of an inflamed respiratory mucous membrane varies 






THE LARYNX. 377 

according to the intensity, and also according to the character of the 
inflammation, from a bright crimson or scarlet, to deep purple or dusky 
redness. The hyperemia is often found to be entirely local ; this is 
chiefly the case in chronic affections: thus, we may find it limited to the 
larynx, the trachea, or the bronchi. The character of the inflammation 
necessarily determines the nature of the products which occur upon and 
beneath the membrane. The most acute form is probably that in which, 
from the contact of a powerful irritant, such as boiling water, an in- 
stant effusion of serum takes place in the submucous tissue, causing its 
distension or cedematous swelling. We have already alluded to the 
cases in which children have met with their death in consequence of 
drinking the hot contents of a kettle from its spout. In some of these 
it appears that the oedema rather affects the parts below the epiglottis 
than the epiglottis itself. Here, it is rather the mechanical effect of the 
tumefaction of the loose tissue at the glottis than the intensity of the 
pathological process, that produces the fatal issue. In catarrhal inflam- 
mation of the larynx, the dyspnoea, and affection of the voice, depend 
mainly upon the amount of tumefaction of the rima glottidis ; during 
the first stage there is, as elsewhere, in the mucous membrane a sense 
of titillation, roughness, and pain ; and as the stage of secretion super- 
venes, these symptoms subside and are relieved by expectoration. This 
presents various appearances to the naked eye; at first, it is a glairy 
viscid mucus, which subsequently assumes a greenish or yellowish color, 
losing its adhesiveness and forming into opaque rounded pellets. If a 
blennorrhaeic state supervenes, the discharge assumes a purulent cha- 
racter. Under the microscope these varieties can scarcely be distin- 
guished. In each, we find mucous corpuscles and epithelium ; and if the 
inflammation has been of sufficient intensity to cause hemorrhage, we 
shall also discover blood-corpuscles. Idiopathic laryngitis appears 
generally to be the result of atmospheric changes ; it runs a rapid 
course, and it is one of those affections in which the performance of 
tracheotomy may become the means of saving the patient's life. The 
disease acquires an historical interest, from the circumstance that it 
proved fatal to Washington. Rokitansky describes, under the name of 
gonorrhceal catarrh of the larynx, a variety which he attributes to me- 
tastasis; he considers it important on account of its leading to a con- 
traction of the passage. He states it to attack the mucous membrane 
of the epiglottis and the duplicatures of the glottis, converting the 
mucous membrane and subjacent areolar tissue into a fibro-lardaceous 
white resistant structure of tolerable thickness, thus giving rise to con- 
traction of the rima glottidis and the cavity of the larynx. 

In children, catarrhal inflammation of the larynx may produce all 
the symptoms of croup ; in which case, though, as Andral observes, the 
passage of air through the contracted rima gives rise to the well-known 
sound of croup, the post-mortem examination will only exhibit a slight 
tumefaction of the mucous membrane, without any trace of the mem- 
branous exudation, which Bretonneau, Copland, and others consider as 
characteristic of the disease. On this subject, the morbid anatomist 
still continues at issue with the nosologist, a circumstance which must 
be attributed to the unwillingness, not to call it by a stronger term, of 



378 THE LARYNX. 

the former to recognize any other proof of disease than that discovera- 
ble by the scalpel. It appears difficult to avoid seeing that the pecu- 
liar disposition existing in infancy to spasmodic affections, dependent 
upon great irritability of the excito-motor system, may convert the 
most trifling irritant into a cause of danger and death, which would not 
be demonstrable by our present means of examination ; even in marked 
cases of diphtheritic exudation, the child does not always die of the 
mechanical obstacle, but by the indirect influence it exerts in producing 
glottic spasm. The variations presented by croup are numerous, and 
depend upon atmospheric causes, or upon peculiarities of living, regi- 
men, and residence. 1 

The larynx is the most frequent seat of croupy exudation, and though 
occasionally found to extend even into the smaller bronchial ramifica- 
tions, the deposit in the trachea and bronchi appears invariably to be 
continuous with the laryngeal exudation. On the continent, more com- 
monly than with us, the exudation also forms on the velum palati, and 
in the fauces and pharynx; according to Bretonneau's 2 observations 
during an epidemic at Tours, the exudation occurred simultaneously in 
the gullet and air-passages, in fifty cases, while in one only the former 
was unaffected. Six or seven times he found that the membranous 
concretion extended to the smallest bronchi, and in one-third of the 
entire number it reached beyond the main division of the bronchi; in all 
the rest it terminated at different points of the trachea. In this form 
it has received the name of diphtheritis, or pellicular inflammation. The 
exudation itself is of an albuminous character, of greater or less con- 
sistency—we have seen it of a translucent jelly-like character, scarcely 
adherent to the parietes — though commonly it presents the appearance 
of a thin and tolerably firm layer, moulded upon the mucous membrane, 
varying in thickness from a mere film to a coat a line and a half in 
diameter. It then exhibits the ordinary appearance of fibrin; of a light 
yellow or cream color; more or less intimately attached to the mucous 
membrane ; from the latter it may, however, always be separated, leaving 
its surface entire, and generally of a bright red. The functions of the 
mucous membrane appear to have undergone an entire revolution; the 
secretion resembling rather that of a serous membrane in tenacity, ad- 
hesiveness, and coagulability. It is deposited in patches, which may 
gradually coalesce, and thus form rings or channels of greater or less 
extent; they send off small prolongations into the follicles scattered over 
the mucous membrane, by which they are secured in their place until a 
suppurative process underneath, loosens them, and allows them to be 

1 The reader is particularly referred to the nineteenth and twentieth Eectures in Dr. 
West's work on the Diseases of Infancy, &c. 

Croup is a disease known by a great variety of names, which are calculated to embar- 
rass the student. Cynanche is the oldest term, under which it is described by Paulus 
^Egineta, as a well-known affection (see the Sydenham Society's Edition of his work, vol. 
i. p. 464); modern writers term it promiscuously cynanche, angina, trachitis, with the 
epithets membranacea, polyposa, stridula, diphtheritis, pellicular inflammation, asthma 
acutum infantum, &c. The English name croup is of Scotch origin, and was first, we 
believe, introduced into general use by Sir Everard Home. 

2 Des Inflammations Speciales du Tissu Muqueux, &c, par P. Bretonneau. Paris, 1827, 
p. 32. 



THE LARYNX. 379 

thrown off, if the patient retains strength to do so. No chemical or 
microscopic difference has hitherto been shown to exist between croupy 
exudation and the product of acute inflammation of serous membranes, 
or of the fibrin of the blood. The hue of the subjacent tissues in cases 
accompanied by great disturbance of the circulation, or with typhoid 
symptoms, becomes dusky and livid. There rarely are any abrasions 
of the mucous membrane of the trachea. If there is more than usual 
difficulty in removing the false membrane from the larynx, this depends, 
as Dr. West 1 remarks, upon the more extensive alterations which this 
part of the air-tube has undergone. It is generally red and swollen, 
especially about the edges of the rima glottidis, the arytenoid cartilages, 
and the openings of the sacculus laryngis. It is in the former that we 
occasionally find small aphthous ulcerations. In that form of croup 
which succeeds to measles, we are informed by Dr. West, that there is, 
in many instances, a condition of unhealthy inflammation, and aphthous 
ulceration of the mouth and gums; a slight speck of ash-colored false 
membrane covering each little ulcer. 

The diseases with which croupy inflammation is most frequently com- 
plicated are bronchitis and pneumonia; though we very commonly meet 
with no other symptoms of morbid action than those found in the part 
affected ; nor is there any doubt that these may be so slight as altogether 
to escape observation, in the post-mortem examination. We must here, 
as elsewhere, be careful not to mistake the pulmonic congestion, resulting 
from the suffocative influence of the malady, with inflammatory action. 

The disease which we have just considered is almost exclusively a 
disease of early childhood. The aphthous ulcers found as a result of 
aphthous stomatitis, or muguet, are equally peculiar to infancy. It is 
not so with the ulcerations which constitute an affection termed phthisis 
laryngea, which accompany tubercular phthisis of the lungs, and rather 
belong to puberty and the later periods of life. It has been long thought 
to constitute an idiopathic disease, but morbid anatomists are now agreed 
that it occurs only as a sequela of tubercular disease of the lungs, and 
also that it is very questionable whether it is ever preceded by the 
deposit of tubercle in the larynx itself. With regard to the latter point 
we must not, however, overlook the statement of Rokitansky, that it is 
deposited in the form of gray granulations in the submucous areolar 
tissue, or as yellow caseous matter, infiltrated into the mucous membrane. 
He has found it constantly and exclusively in the vicinity of the trans- 
verse muscles and the adjacent arytenoid cartilages. His experience 
is strikingly at variance with that of Louis, who has not in a single 
instance met with tuberculous granulations in the substance, or on the 
surface of the epiglottis, larynx, or trachea. Dr. Watson attributes 
these ulcers exclusively to the acridity of the sputa; but, although the 
sputa manifestly exercise an influence in their production, there must be 
some further cause, as they are by no means constant accompaniments 
of phthisis, and as they do not form at some points, e. g. the ventricles 
of the larynx, in which a lodgement of sputa must constantly take place. 
Louis states ulcers in the larynx to have occurred in a fourth part of 
his cases. 

1 Lectures on the Diseases of Infancy, 2d ed. p. 221. 



380 



THE TKACHEA. 



Fig. 177. 



In children, ulceration of the air-passages is scarcely ever met with ; 
Dr. West 1 has only seen it once in early life ; on that occasion, several 
small excavated erosions were found, just above the chordae vocales, in 
a child of twenty months, besides a general redness of the bronchial 
tubes. In the larynx, their site is generally at the junction of the 
vocal chords, on the vocal chords themselves, and on the arytenoid 
cartilages. 

Ulceration of the mucous membrane may extend to the cartilages of 
the larynx ; or these may be primarily the seat of inflammatory action, 
as the result of deep-seated cachexia, such as syphilis. To this cause 
we must also refer the epithelial formations or polypoid growths, which 

are occasionally found springing from the 
mucous lining of the larynx. Cancer no- 
dules of the medullary variety are also met 
with in these parts, and Rokitansky de- 
scribes, as a very singular form, a cancerous 
degeneration of the arytenoid cartilages. 
These affections are generally accompanied 
by symptoms of chronic laryngitis, consist- 
ing in reddening and serous infiltration and 
hypertrophy of the surrounding tissues ; 
with wasting and degeneration of the laryn- 
geal muscles, and occasionally the forma- 
tion of abscesses in the submucous layer. 

The laryngeal cartilages have a tendency 
to ossify in advanced life in obedience to 
the general-law affecting similar structures; 
but this metamorphosis is also produced by 
disease; and it is probably in those cases of 
chronic laryngitis chiefly, which are con- 
nected with a rheumatic diathesis and origi- 
nate in the perichondrium, that this meta- 
morphosis takes place. The larynx is not 
so liable to be affected by tumors or foreign 
bodies pressing upon it as other parts of the 
respiratory system, on account of the greater rigidity of its walls, and the 
capaciousness of its interior. Foreign bodies arrested in the oesophagus 
generally become impacted behind the larynx ; when introduced by the 
glottis, they may become fixed in the chink ; but if they pass the portal 
they necessarily drop through the wider cavity of the larynx, and 
become fixed at some lower point, or play up and down in the trachea. 




Ulceration of the larynx. 



THE TRACHEA. 



Many of the observations which we have had occasion to make on the 
pathology of the larynx apply to the trachea. The congestion of the 
mucous membrane presents similar characters; it is generally observed 



1 The Diseases of Infancy, 1st ed. p. 71. 



THE TRACHEA. 



381 



to be most marked in the membranous interstices, between the rings 
and at the posterior part. Occasionally, it is bounded by a sharp out- 
line; thus, where the hypersemia of the trachea is associated with disease 

Fig. 178. 





Enlargement of follicles of mucous membrane of the trachea, closely resembling miliary granulations, and 
accompanying pulmonary phthisis. The drawing on the right is an enlarged view of a single follicle, sur- 
rounded by enlarged and congested vessels. The glandular structure was distinctly apparent when examined 
under a higher power. 

of one lung, it may be seen on the corresponding half of the former only, 
the mesian line forming the division between the normal pale tissue and 
the portion that presents increased vascularity. A similar observation 
has been made with regard to the occurrence of ulcers, viz: that when 
following unilateral pulmonary disease, they are confined to the corre- 
sponding side of the trachea. Otherwise, the point of divergence of the 
bronchi and the posterior mesian line are the most frequent seat of 
tracheal ulcers. They may often be traced to follicular inflammation, 
in the same way as obstructed solitary follicles put on the appearance 
of tubercular deposit. The essential connection between ulceration of 
the trachea and pulmonary phthisis is even more firmly established than 
in regard to the relation between the latter and laryngeal ulceration. 
Louis 1 found that, of 190 phthisical subjects, seventy-six presented 
ulcerations in the trachea ; while in 500 non-phthisical subjects, carried 
oft by chronic diseases, examined by the same pathologist, not one pre- 
sented any tracheal or laryngeal ulceration. A curious circumstance 
connected with this question is the different ratio in which the two sexes 
are affected ; thus, Louis has shown that, while only about one quarter of 
the females who succumb to pulmonary consumption exhibit ulcers in 
the trachea, they are found in half the male subjects similarly diseased. 

Croupy inflammation of the trachea presents no characters which differ 
from the phenomena exhibited by the disease when affecting the larynx 
alone. 

The rings of the trachea, like the cartilaginous structures of the 



On Phthisis, Syd. Soc. Ed. p. 42. 



CHAPTER XXVII. 

THE BRONCHIAL TUBES. 

The diseases of the bronchial tubes affect the individual very differ- 
ently, according as the larger or smaller divisions are the seat of the 
morbid action. Thus, the same amount of tumefaction which, in the 
mucous membrane of the bronchi near the trachea, will scarcely give 
rise to any inconvenience, will, in the finer ramifications, be the cause 
of intense dyspnoea and danger. The terminal points of the respiratory 
system, in this respect, resemble each other ; an acute tumefaction about 
the aperture of the larynx, and at the opposite end of the bronchial 
tree, may equally induce suffocative symptoms. Moreover, it is not 
always easy to determine the limits of bronchial and parenchymatous 
disease of the lungs ; and it is scarcely possible that inflammatory affec- 
tions of the latter can take place without involving the smaller bronchi. 
Hypersemia of the bronchial mucous membrane is a phenomenon of 
every-day occurrence, accompanying catarrh, gastro-intestinal, hepatic 
or cardiac affections, and manifested in its most marked forms by hemor- 
rhage. Haemoptysis is rarely idiopathic as a mere result of plethora, 
but commonly associated with a deeper-seated morbid affection ; a crasis 
subsequently manifesting itself by further disorganization, or an organic 
disease, which has already been discovered. Pathologists have not yet 
succeeded in demonstrating the exact manner in which capillary hemor- 
rhage takes place; in a few instances of advanced tuberculosis, patulous 
vessels which were eroded by the progress of the ulceration, have been 
discovered, to which pulmonary hemorrhage could be attributed; but 
the common process by which the blood is discharged, is undoubtedly 
analogous to the "sweating" of blood by which the menstrual flow has 
been observed to be effected ; it is rather by exhalation or secretion that 
the overloaded vessels relieve themselves, than, as the term hemorrhage 1 
implies, by laceration or rupture. The hemorrhage is not a mere pas- 
sive occurrence, resulting from a retardation of the vascular current, or 
we should find it accompanying hypostatic congestion, which it does not; 
it must be looked upon as an evidence of further disease of an active cha- 
racter, as a symptom calling for our careful attention, but only to be 
treated in reference to a fundamental affection. Hemorrhage from the 
lungs by exhalation rarely proves fatal in itself, though at times the 
amount of blood lost is very considerable. Dr. Copland quotes the case 
of a patient who lost about 192 ounces in twenty-four hours, and reco- 

1 Hemorrhage, etymol. aTfxa, blood; fiywfAi, I rupture; p*y*<;, a cleft, a fissure. 



THE BRONCHIAL TUBES. 



385 



vered. The frequency with which it is associated with phthisis, has 
been determined by Louis to be about two-thirds of all the cases ; a re- 
lation which is confirmed by recent observers, and one which, taken with 
other circumstances, casts much suspicion on the nature of the cases of 
so-called vicarious hemorrhages, whether they take the place of the 
menstrual or hemorrhoidal discharge. With regard to the former, we 
cannot overlook the very frequent derangement of the ovarian function 
in company with tubercular disease of the lungs; and if we add to this 
the demonstrated connection between haemoptysis and phthisis, it is diffi- 
cult to avoid seeing that vicarious menstruation of this character is 
almost necessarily indicative of a tubercular tendency. The difficulty 
of explaining the mode in which haemoptysis takes place, is as great in 
regard to the stages of softening as in the earlier stage of crudity ; 
the vessels become obliterated in the former instance as the tubercular 
matter and pulmonary tissues deliquesce, and we are rarely able to dis- 
cover the open mouths of lacerated vessels. At a future page, we shall 
also have occasion to see that the hemorrhage into the tissue of the 
organs constituting pulmonary apoplexy, is distinct from that bronchial 
hemorrhage with which haemoptysis is commonly associated. In either 
stages, therefore, of tubercular disease, it remains for us only to assume 
that the congestion takes place on the bronchial mucous membrane, and 
that the discharge which ensues, is a symptom of the blood crasis rather 
than of the local affection to which it has given rise. The relation of 
haemoptysis to the different stages of phthisis, is one to which Dr. 
Walshe 1 has especially directed his attention ; the results of an analysis 
of the cases which had occurred at the Hospital for Consumption at 
Brompton, in reference to this question, are as follows: — 





Number of cases. 


Frequency of Haemoptysis. 




Absolute. 


Per cent. 


First stage 

Second stage ........ 

Third stage 


39 
20 
69 


28 
18 
57 


71.79 
90.00 
82.61 



The proportion changes somewhat, when the analysis is made for each 
of the sexes ; we then find that the increase of haemoptysis during the 
second and third stages is considerably greater in men than in women, 
which may fairly be explained by the greater bodily labor, and increased 
tax upon the pulmonary circulation, in the former than in the latter; it 
rather tends to show that the exciting influence of the tubercular ca- 
chexia itself, in producing the hemorrhage, is greater than that of its 
secondary results. The following is the table illustrating this point : — 

1 Medico-Chiriirgical Review, vol. iii. p. 225. 



25 



386 



BRONCHITIS, 





MALES. 


HEMOPTYSIS. 


FEMALES. 


HEMOPTYSIS. 




Number of 
cases. 


Absolute 
frequency. 


Per cent, 
frequency. 


Number of 
cases. 


Absolute 
frequency. 


Per cent, 
frequency. 


First stage 
2d and 3d 
stages 


18 


12 
49 


66.66 
87.50 


21 
33 


16 
26 


76.19 
78.78 



We forbear entering into a further disquisition of this point, as it 
would carry us beyond our prescribed limits ; we cannot, however, avoid 
pointing out, that it bears most immediately upon the question of the 
treatment of the early stages of phthisis, for if, as we would conclude, 
the hemorrhage is a local symptom of the general cachexia, the indica- 
tions would be to remove the local congestion by non-debilitating counter- 
irritation, while we correct the constitutional taint by the remedies which 
we know to be capable of doing so. Neither, alone, would be likely to 
suffice, nor would anything appear more objectionable than the employ- 
ment of remedies applicable to a state of plethora and general vascular 
excitement; we allude more particularly to venesection and mercurials. 



BRONCHITIS 



180. 



In inflammation of the bronchi we find the same variations of injection 
and secretion that are presented to us in similar conditions of the upper 
portions of the air-conduit; but the nearer we approach the terminations 
of the subdivisions, the more the bronchules will be found filled with the 
fluids poured into them, corresponding in character, in a measure, to 
the sputa seen before death, but with a greater 
admixture of air, the less viscid and tenacious the 
secretion. The post-mortem appearances may 
be limited to mere redness of the mucous mem- 
brane. In the smallest subdivisions, we must be 
careful to discriminate between the injection of 
the bronchules, and the redness resulting from 
the translucency of their tissue, allowing the color 
of the subjacent pulmonary parenchyma to shine 
through. The redness is generally tolerably 
uniform in the part affected, fading off at the 
margin into the healthy tissue; we do not com- 
monly meet with that arborescent or punctiform 
injection in the bronchi, which is seen in inflam- 
mations of other mucous membranes, as that of 
the stomach. Sometimes the affection resides 
exclusively in the larger bronchi, fading off in 
the smaller divisions ; at others it occupies the 
reverse relation; the danger to the individual 
increasing with the number of small tubes af- 
fected ; the tumefaction and loss of elasticity in 
which, necessarily exert a great influence in 




«Miw ; 



Injection and stasis in tbe ves- 
sels of the bronchial mucous 
membrane, in bronchitis, seen by 
a low power. The vessels were 
disposed in longitudinal clusters, 
united by transverse inoscula- 
tions. 



BRONCHITIS. 387 

producing dyspnoea. The actual sense of the difficulty of breathing, 
as well as the real absence of proper aeration of the blood, shown by 
the lividity of the patient, has appeared to us to be greater in these 
cases of capillary bronchitis than in pneumonia. The more asthenic 
the form of bronchitis, the more the redness of the bronchial mucous 
membrane approaches a livid purplish tint; it is generally found of 
this hue in the chronic forms. The secretions will vary according to 
the stage and character of the disease, from a viscid glazy mucus, 
to a genuine purulent discharge of a more or less diffluent character. 
Occasionally, death is the result of a sudden effusion of liquid into the 
bronchi, constituting what is called suffocative catarrh, which is met 
with more frequently in the infant than in the adult. Long-continued 
purulent expectoration may, however, have existed during life, without 
any appreciable lesion being discovered after death; in these cases, the 
bronchial mucous membrane, as Andral 1 observes, need not even present 
a trace of redness. In examining the lungs, we must be careful to com- 
pare different portions, before arriving at definite conclusions; for it is 
often difficult to determine to which part the fluids belong which exude 
on section. The surest way to ascertain the state of the parietes and 
contents of the bronchi, is to follow them from the larger trunks with a 
pair of scissors, carefully avoiding to admit more extraneous matter into 
the tubes than we can help. 

Croupy inflammation may affect the bronchi, as it does the upper 
respiratory passages, though it does so with less frequency; complete 
moulds of portions of the bronchial tree present themselves to us; the 
influence they exert upon respiration depends partly upon the obstruc- 
tion they themselves offer, and partly upon the tumefaction of the sub- 
jacent mucous membrane. 

The mucous membrane of the bronchi, like the mucous membranes of 
the urino-genital organs, occasionally exhibits a chronic affection, in 
which, without marked symptoms of an inflammatory character, the 
membrane pours out a plastic exudation, which forms what has been 
termed bronchial polypi. Their microscopic characters have not as yet 
been determined, but, if a surmise may be hazarded, we should expect 
to find them consisting of epithelium, matted together by an unusually 
viscid mucus. Dr. Watson observes, that though it is surprising that 
patients should recover from the affection, it never in itself seems to 
prove fatal. Dr. Reid 2 has reported two cases of tubular expectoration 
from the bronchi, occurring in the adult, with delineations, which closely 
resemble that given by Dr. Baillie, in his work on morbid anatomy. In 
one, the patient, a married lady, aged twenty-eight, affected with a 
chronic cough, consequent upon an attack of bronchitis, frequently, 
after suffocative attacks, coughed up arborescent membranous sub- 
stances, resembling casts of the minute bronchial tubes: the second 
case occurred in a gentleman, aged forty-four, and closely resembled 
the former, except that there was more manifest congestion, and that 
the casts were more of a sanguineous character, and their rejection each 

1 Precis d'Anatomie Pathologique, ii. 481. 

2 Medico-Chirurgical Transactions, vol. xxxvii. p. 333. 



388 BRONCHITIS. 

time accompanied by some hemorrhage. It appears to be more frequent 
on the continent of Europe, where the affection has carried off several 
distinguished individuals, among whom the Empress Josephine is the 
most eminent. 

Other morbid states, besides those already alluded to, may give rise 
to a constriction or stenosis of the bronchial tubes ; it may be produced 
by an actual hypertrophy of the submucous layers, as a result of 
chronic bronchial irritation, or by serous effusion, as in dropsical states 
of the system. The physical symptoms in these different cases may be 
identical, being produced by analogous structural alterations ; but it is 
manifest that the constitutional basis upon which they rest may differ 
very considerably, as also the influence they exert in living subjects 
upon the further production of morbid conditions. 

The pulmonic symptoms accompanying typhous and typhoid fevers, 
is set down by Rokitansky 1 among the class of catarrh of the mucous 
membrane; he states it always to appear as an intense diffused conges- 
tion ; the mucous membrane is of a dark, almost violet tint, swollen and 
succulent, and yields a secretion of a gelatinous and sometimes dark, 
blood-streaked mucus. The disease, according to this author, is most 
commonly developed in the bronchial ramifications of the lower lobes ; 
it is always limited to the stage of typhous congestion, and never gives 
rise to any apparent production of a secondary formation on the tissue 
of the mucous membrane, such as is produced in immense quantity in 
the intestinal follicles in cases of abdominal typhus. He based his 
diagnosis of a primary broncho-typhus, in which the disease is localized 
here to the exclusion of all other mucous membranes, upon the peculiar 
stasis and swelling of the spleen, and at the cul-de-sac of the stomach, 
the remarkable character of the blood, the typhous nature of the gene- 
ral disease, and especially the altered condition of the bronchial glands. 
The last lesion of the bronchial mucous membrane which remains for 
our consideration is, ulceration; as in the larynx and trachea it is 
mainly, if not exclusively, a concomitant of phthisis. It has been ob- 
served by few authors, probably on account of the care requisite in the 
examination, to discover an abrasion in these parts. Louis, who ex- 
amined the bronchi of forty-nine phthisical subjects, with special regard 
to this point, found ulcerations in twenty-two. Dr. Copland is of opi- 
nion that ulcers occasionally perforate the bronchial tubes, and thus 
occasion abscesses in the pulmonary parenchyma. 

The submucous tissues may be variously affected in the bronchi, as in 
air-passages already considered. The cartilaginous rings may undergo 
a process of softening or the opposite condition of ossification; in this 
case, they become brittle, and break; they then either project like fish- 
bones, as Andral observes, into the bronchial cavity, or, becoming de- 
tached, are expectorated. 

1 Pathological Anatomy, vol. iv. p. 23, Syd. Soc. Ed. 



DILATATION OF THE BRONCHI. 389 



DILATATION OF THE BRONCHI. 

Many of the lesions which we have adverted to may co-operate in 
producing a morbid condition of the bronchi, to which Laennec was the 
first to draw attention, and which, though of extreme importance in a 
nosological point of view, has hitherto been rather treated as a question 

Fisc. 181. 




Dilated bronchi, from a female aged 52, -who had suffered from chronic pneumonia and bronchitis for three 
years ; the pulmonary tissue intervening between the bronchi was much condensed. 

affecting the pathologist than the practitioner. It is dilatation of the 
bronchi or bronchiectasis. 1 By Laennec, it was attributed exclusively 
to an accumulation of mucus in the ramifications of the dilated portion ; 
but, as Dr. C. J. B. Williams justly observes, if this were the cause we 
should not, as we do, hear the air penetrate freely into the dilated por- 
tions. There may, undoubtedly, be various efficient causes at play in 
the production of this diseased state, both of a mechanical and of a more 
dynamical character. The most palpable instance of the former is pre- 
sented to us in the case of an enlarged bronchial gland, whether it con- 
tains cretaceous or simply scrofulous matter, compressing a bronchus. 
Here, the free exit of the respired atmosphere being prevented, an 
accumulation of air might be supposed to take place behind the narrowed 
portal, the channels being prevented ever collapsing to the same extent 
as a healthy lung. Any impediment to the entrance or exit of the air 
into the lungs will produce irregular and forcible breathing, and throw 
a greater strain upon those parts especially, which are in the vicinity of 
the obstacle. 

One point having yielded, it is quite intelligible that the distension 
should gradually progress, while, at the same time, it must, in a cor- 
responding ratio, compress and gradually obliterate the surrounding 

1 Etymology — Bpoyxia, the bronchi, and hrac-isy dilatation, from hnim, I stretch. We 
may take this opportunity of remarking upon the distinction which some authors have 
lately made between bronchia and bronchi ; it is a source of some confusion, and scarcely 
warranted by their etymology of the words ; if a diminution is required, the term bron- 
chule is more convenient, and not liable to be mistaken. 



390 



DILATATION OF THE BRONCHI. 



pulmonary tissue. In the majority of instances a diseased condition of 
the bronchial parietes, if not, as Corrigan has suggested, of the pulmo- 
nary parenchyma itself, precedes the occurrence of bronchiectasis. 1 

Fig. 182. 




Cretaceous enlargement of a bronchial gland compressing the right bronchus, which is much dilated 

beyond the point. 

When the changes have taken place in the tissues which are likely to 
give rise to it, any violent effort to distend the lungs, as in catarrh, 
bronchitis, or hooping-cough, may be the exciting cause. The three 
forms which Laennec 2 describes have been successively adopted by sub- 
sequent writers, though none have been satisfied with his rationale. In 
the first there is a solitary cystic dilatation — in the second, a series of 
distinct dilatations of a more or less circular form, commonly affecting 
bronchi of the third and fourth order ; these two forms are essentially 
the same, and they generally present considerable attenuation of the 
dilated portions, while the intervening parts of the bronchi remain nor- 
mal. Laennec's third form differs entirely from those just considered, 
and consists in an almost uniform or cylindrical expansion of a single 
tube, or an entire section of the bronchial tree. Here it is we meet 
with thickening of the parietes, tumefaction of the mucous membrane, 
which may be thrown into folds resembling those of the small intestine, 
and a proportionate increase in the subjacent fibrous tissue. When the 
dilatation affects the apex of the lung, it may proceed to such an extent 
as to resemble a tuberculous multilocular cavity. The perfect continuity 

1 Corrigan views the condition of the pulmonary tissues, giving rise to bronchial dila- 
tations, as analogous to cirrhosis of the liver ; he considers it the result of the formation 
of an unyielding fibrous tissue, to which the bronchi become attached, and therefore inca- 
pable of collapsing. 

2 See Laennec's Traite de 1' Auscultation Mediate, &c, 1826, vol. i. p. 206. 



DILATATION OF THE BRONCHI. 391 

of the mucous lining with that of the adjoining bronchi, and the smooth- 
ness of the tissues, will aid in determining the nature of the lesion, if 
there is any doubt. The explanation offered by Hope 1 of the mode in 
which bronchitis, the most frequent exciting cause of bronchiectasis, 
gives rise, is so satisfactory, that we give it in his own words: First, the 
air-passages are stripped of their epithelial lining in the ordinary man- 
ner; their canals becoming loaded in part with a mucous secretion, in 
part plugged with fibrinous exudation. This latter occurrence takes 
place chiefly within certain of the lesser twigs, occasioning a collapse of 
the adjunct air-cells. The space thus set free, is sought to be filled up 
by the expansion of the neighboring parts, giving rise, in the majority 
of cases, to emphysema; where, however, the collapse does not occur 
close beneath the surface of the lining, but at a greater depth, and near 
a larger bronchial tube, and when it comprehends a larger tract of pul- 
monary substance, the result is bronchiectasis ; these circumstances do 
not, however, suffice for the formation of a bronchial cavity, the parietes 
of the involved bronchial tube must needs have previously suffered the 
changes pointed out by Stokes — namely, loss of elasticity in the longi- 
tudinal, and of contractile power in the annular fibres, with consequent 
incapacity on the part of either to resist the mechanical influence of 
forcible inspiration or of violent cough. 

- It appears from Dr. West's description, that in children the fusiform 
variety of bronchial dilatation is rarely, if ever found, while the cylindrical 
form is a common result of bronchitis. On one occasion, however, he 
saw a case in which, in addition to a general cylindrical enlargement of 
the tubes, many of them presented a marked dilatation, about half an 
inch from their termination the tube expanding into a cavity big enough 
to hold half a large nut. The lining mucous membrane presented an 
extraordinary degree of thickening. 

Tubercular deposit in the bronchial tubes is an affection spoken of by 
Rokitansky alone among authors ; he describes it, under the term of 
bronchial tuberculosis, as an infiltration of the mucous membrane with 
yellow, lardaceous, caseous matter, into which the former at last appears 
to be converted; the bronchial tube becomes enlarged, its channel finally 
obstructed by tubercle, while its fibrous sheath is infiltrated with larda- 
ceous matter, callous and thickened. He states that it occurs second- 
arily to tuberculous abscesses, but that the primary form, commencing 
in the ultimate ramifications of the bronchi, and extending backwards 
into the larger tubes, is by far the more important form. The latter 
may be found unassociated with genuine pulmonary tubercle, and it may, 
by softening and breaking down of the bronchial walls, give rise to 
abscesses resembling those of vesicular tuberculosis ; at the same time, 
the author admits that this mode of the formation of abscesses is infinitely 
less frequent than that commonly known. The primary form of bron- 
chial tuberculosis, Rokitansky describes as most common in childhood, 
being usually associated with all the tuberculoses of other organs peculiar 
to this period of life, and especially with intense tuberculosis of the 
bronchial glands. 

1 Pathological Anatomy, Syd. Soc. Ed., p. 297. 



392 DILATATION OF THE BRONCHI. 

In addition to the varieties of mucous, purulent, and hemorrhagic 
sputa, and to the foreign bodies occasionally introduced from without, 
to which we have already alluded, we occasionally find in the bronchial 
passages calcareous concretions, derived from obsolete tubercular deposits, 
bile or bile-tinged pus, derived from a fistulous opening through the 
diaphragm, communicating with the liver fragments of pulmonary tissue, 
recognizable by the elastic fibres shown under the microscope, and cysts. 
The latter are extremely rare, and are probably always derived from the 
pulmonary parenchyma, or the liver. We have not seen any case 
recorded of their formation in the bronchi. Hasse 1 states, that he has 
seen a pellucid vesicle, of the size of a hemp-seed, on the left vocal cord, 
and he mentions cases recorded by other observers of hydatids in the 
same region. 

1 Pathological Anatomy, Syd. Soc. Ed., p. 378. 



CHAPTER XXVIII. 

THE LUNGS. 

Having in the foregoing pages considered the diseases of the respira- 
tory passages, we now arrive at the investigation of the morbid changes 
which occur in the lungs themselves ; in the tissues aiding in the pur- 
poses of oxygenation, the ultimate vesicular terminations of the bronchi 
and the interlobular tissue. The bronchules, long before their termi- 
nation, are deprived of their cartilaginous rings ; these are reduced to 
mere flakes before they cease altogether, and all trace of them disap- 
pears, according to Messrs. Todd and Bowman, 1 in tubes of less than 
one-sixth to one-tenth of an inch in diameter. The tracheal muscular 
fibres are described by these physiologists as being continued even to 
the terminal bronchules, but instead of merely filling up the gap in the 
cartilaginous framework, they form a uniform layer encircling the canal, 
but excessively thin. Within the muscular layer is that of the longitudi- 
nal or elastic fibres ; the ciliated epithelium and basement membrane 
of the mucous tissue descend into the terminal bronchules. The air- 
vesicle itself is described as formed of one coat only, resulting from a 
fusion of the elastic coat and basement membrane, and it is stated to 
contain no epithelium. Whether the latter point is correct or not, the 
extreme tenuity of the vesicular coat is an undoubted fact ; nor could it 
be expected otherwise, when we consider that the part it plays is to 
prevent the air from being diffused into the interstitial tissues, and that 
the exchange of the oxygen of the atmosphere, and of the carbonic 
acid of the blood, could only be effected with sufficient rapidity through 
an infinitely delicate texture. We premise so much of the healthy 
anatomy of the lung, in order to render it evident that the difference 
in its texture would produce different morbid symptoms, as well as differ- 
ent post-mortem results, than those exhibited in diseases of the air- 
passages. While the latter possess their own peculiar secretions, which 
tend to modify or relieve the perverted action of their constituents, the 
effect of disease upon the true pulmonary tissues must be, to cause a 
more immediate interference with the vital functions, by altering the 
caliber of the air-reservoir from without or from within. The air-vessels 
themselves are solitary globular sacs, terminating a minute bronchule, 
and arranged along a larger bronchule like a bunch of currants, or pre- 
senting a corymbose or racemose appearance more analogous to a bunch 
of grapes. The vesicles are never angular or polygonal, until subjected 

1 Physiological Anatomy, chap. xxix. 



394 THE LUNGS. 

to pressure resulting from some pathological process. When intravesicu- 
lar effusion is limited to a few scattered vesicles, the globular appearance 
is only rendered more conspicuous ; and in no case has it appeared to us 
that the human lung offers, in its ultimate terminations, any resemblance 
to the honeycomb arrangement seen in the lungs of the lower animals, 
and produced by a reduplication of the basement membrane, so as to 
form septa, projecting into the cavity of the vesicle. 

The anatomical characters of the vesicular structure, and the little 
support it has compared with the denser tissues of the bronchi, easily 
explain the first morbid condition to which we shall advert — Vesicular 
Emphysema. Dr. Baillie, though unable to suggest the means of dis- 
tinguishing the disease before death, was one of the first to show its 
true nature in the dead body. It consists essentially in a dilatation of 

Fig. 183. 




Portion of emphysematous lung — the cavities are either formed by simply enlarged air-cells, or by the 
coalescence of groups of cells. — St. Bartholomew's Museum, xiv. 11. 

a larger or smaller number of air-vesicles, and may be produced by any 
cause exerting a great strain upon them. The effect is to diminish the 
specific gravity of the part affected, so as to render it more buoyant 
than the healthy lung tissue in water ; to cause the lung to become less 
crepitant on compression, giving it a doughy or woolly feel, to prevent 
its collapse on the thorax being opened, and to render it more or less 
dry and exsanguine. The emphysematous portion, if superficial, pro- 
jects above the surface of the unaffected part ; and large bullae may be 
visible on the surface of the lung, from the gradual obliteration of the 
intervesicular tissue, allowing several vesicles to unite. The loss of 
elasticity in the pulmonary tissue, whether primary or secondary, pre- 
vents the usual collapse of the lung at the period of expiration ; the 
vitiated air is not expelled as it ought to be ; hence arises a great want 
of oxygen, and the patient, on the slightest aggravating cause, is seized 
with a fit of asthma ; the consequence of this permanent dilatation of 
the organ necessarily affects the thoracic parietes ; if one lung only 
is affected, the corresponding side enlarges, and becomes less movable 
than its fellow ; the adjoining viscera are more or less displaced ; the 
intercostal and supraclavicular spaces swell out ; the ribs, instead of 
slanting downwards, stand out horizontally from the vertebral column, 
and are almost immovable, giving to the thorax that barrel-shaped form, 



THE LUNGS. 395 

which alone is considered indicative of emphysema. In horses, this is a 
very common disease, and constitutes the vice termed "broken wind," 
which veterinary surgeons state to be chiefly due to overworking after 
a full meal of green meat. Veterinary surgeons have observed that it 
is hereditary in horses, 1 which tends to confirm the like remark made by 
Dr. Budd, Louis, Hasse, and others, 2 as applied to man. Dilatation of 
the bronchi is a pathological condition frequently associated with vesi- 
cular emphysema, and may be attributed to the same cause. 

Mr. Rainey, in one of his interesting papers in the Medico- C Mr urgical 
Transactions? has attempted to prove, that emphysema is the result of 
over distension of the air-cells, brought on either by their mechanical 
distension, or of the pulmonary membrane undergoing a fatty degenera- 
tion, which enfeebles it, and causes it to give way under the ordinary 
pressure of inspiration. Dr. Gairdner, as we shall see, denies either 
mode of production in the sense of Mr. Rainey, and only admits the 
occurrence of fatty or granular deposits in emphysematous parts as ex- 
ceptional. The microscope confirms what is palpable to the naked eye, 
that the bloodvessels are very scanty. They become compressed in the 
interstitial tissue by the enlarging air-vesicles, and are entirely obliterated 
in the progress of the disease; hence, the emphysematous portion *is ex- 
empt from those morbid affections which are associated with congestion 
or inflammatory conditions, such as hemorrhage, pneumonia, or exudative 
processes. It was formerly supposed that vesicular emphysema was 
mainly due to rupture of the interstitial membrane; we have shown that 
this is not the prevailing circumstance ; still, actual laceration does 
occasionally take place. The largest dilatations are seen along the 
ulterior margins of the lungs, probably owing to these parts being least 
supported. The bullae individual sometimes attain a very considerable 
size. If the dilatation of the air-cells is more generally diffused, the 
lung presents, as Dr. Baillie first observed, the appearance of the lung 
in amphibious animals. 

It is the more important to be well acquainted with the features of 
this malady, as much may be done to anticipate and prevent it, while 
we have little control over it when it is established; the advantage of the 
study of pathological anatomy, as an illustration of morbid processes in 
the lining, is rarely shown in more marked instance than here : the 
knowledge of the actual lesion giving rise to the phenomena of asthma, 
if not in all, yet in the majority of cases, is a warning to those who, 
from indolence or carelessness, are too prone to be satisfied with attri- 
buting spasmodic symptoms exclusively to deranged nervous action. The 
credit of offering the first rational explanation of asthma, and its con- 
nection with emphysema, is due to Dr. Floyer, 4 though the priority of 

1 See Mr. Youatt's work on the Horse, art. Broken Wind. 

2 Med.-Chir. Trans, vol. xxiii. p. 37. 
» Vol. xxxi. p. 297. 

4 In his little work on Asthma, published in 1698, Dr. Floyer says: " The broken wind 
results from the rupture or dilatation of the bladders of the lungs, by which the air is too 
much retained in the bladders or their interstices, and thereby produce a permanent flntu- 
lent tumor in the whole substance of the lungs. It is not easy to explain the production 
of a permanent flatulent tumor in the lungs by a strain in running, but by supposing the 
bladders of the trachea too much distended, and the muscular fibres which constringe them 



396 THE LUNGS. 

the discovery is commonly attributed to Laennec. The views of the 
latter, in regard to the production of the disease, though difficult of 
comprehension, have long been accepted by the profession. He conceives 
that any obstacle to the discharge of air from the lungs may give rise to 
it; he especially attributed it to "dry catarrh;'' in early life, hooping- 
cough, by inducing an over-repletion of the air-vesicles, and a great 
strain upon them; swellings of the bronchial glands, by compressing the 
bronchi, frequently give rise to vesicular emphysema. We have stated 
that Laennec's view of the manner in which emphysema is produced, is 
difficult of comprehension, because a plug that prevents the exit of the 
air is likely to prevent its admission; and although a valve-like action 
may, by a curious combination of circumstances, be induced so as to be 
followed by such an effect, the structure of the bronchial tree forbids 
our assuming its frequent occurrence. There are other still more forcible 
arguments against Laennec's theory, which have been put forward by 
Dr. Gairdner. 1 He remarks that the theory of Laennec, which ascribes 
emphysema to mucus in the bronchi and accumulation of air behind the 
obstruction, is vitiated by the ample proof which now exists, that ob- 
struction of the bronchi has precisely the opposite effect, giving rise to 
voiding of the air-cells and collapse of the lung; he rejects the idea that 
emphysema is dependent upon forcible expirations as utterly untenable. 
Dr. Gairdner has found that emphysema never occurs unaccompanied 
by pulmonary collapse, or by one or other form of pulmonary atrophy ; 
the greater volume of the emphysematous lung depending, not upon 
increase of tissue, but mere distension. He denies that it is ever preceded 
by any altered condition or diminished resistance in the walls of the 
air- vesicles; he has usually found the bronchi leading to affected parts 
entirely unobstructed; and he concludes that emphysema is a lesion oc- 
curring from mechanical causes, in those parts of atrophied and collapsed 
lungs to which it has the most free access; in other words, it is produced 
by atmospheric pressure in the comparatively sound portions of such 
lungs. According to Dr. Gairdner's theory, the increase of volume of 
the emphysematous lung is supplementary to the diminished volume of 
those parts from which the air is excluded ; but the real effect is, that 
while the surface of the breathing membrane is extended, its physiological 
capacity of aeration is much diminished, so that the individual comes to 
labor under two morbid conditions instead of one. Another form of 
emphysema is that to which the name interlobular has been applied, and 
which is analogous to the emphysema occurring on the surface of the 
body; like this, it consists in an effusion of air into the cellular, or rather, 
as applied to the lung, into the interstitial tissue, and is due to a lacera- 
tion of the bronchial tubules or the air-vesicles. It generally induces 
a puffy swelling under the pleura, and is commonly associated with a 
subcutaneous extravasation of air, affecting the chest, neck, and head. 
Emphysema, in its turn, like every disease which impairs the circulation 

in expiration, thereby over-stretched and made unfit to express the air afterwards ; so that 
these bladders retaining more air than is usual, the substance of the lungs must appear 
always inflated." 

1 British and Foreign Medico-Chirurgical Review, April, 1853, p. 452. 



ATELECTASIS PULMONUM. 397 

through the lungs, is liable to induce dilatation of the right side of the 
heart. 

We must be careful to distinguish the two forms of emphysema just 
alluded to from one another, as well as from the post-mortem evolution 
of gas, which may produce similar appearances. In the latter instance, 
there are general indications of decomposition to guide us ; and we shall 
find that the bladders of air that distend the pleura may be easily 
removed by pressure, and the accumulation pushed aside more readily 
than when we have to deal with a pathological product. Nothing, in fact, 
is more difficult than to free an emphysematous portion of lung from air ; 
even in drying it slowly, the diseased cells, as Hasse observes, retain their 
air, whilst the undilated cells dwindle down into a hard and almost solid 
mass. The determination as to the nature of the emphysema may be 
of importance in forensic medicine, in determining the question as to the 
employment of violence in causing the death of an individual. 



ATELECTASIS PULMONUM. 

Diametrically opposed to the condition which we have just considered, 
is one which is peculiar to early life, and frequently has been confounded 
with the results of pneumonia. It consists in the permanence of the foetal 
condition of the lungs; the vesicular structure either not being properly 
developed, or the infant not possessing sufficient force to expand the 
thorax, and cause the dilatation of the breathing apparatus. It was first 
observed, and duly described, by Professor Jorg, 1 under the name of 
Atelectasis Pulmonum; 2 who found that it occurred chiefly in full-grown 
infants of very feeble powers, or in such as had been born prematurely, 
and were, therefore, not in a condition to dispense with the placental 
circulation. The inferior portions of the lungs are most liable to present 
this state : it occurs in patches, which offer a darkened color, do not 
crepitate on pompression, and offer a smooth surface on section. The 
affected part sinks in water. The part or lobule that has not undergone 
the due expansion is below the level of the surrounding dilated lung 
tissue ; hence, a lung affected in this manner does not fill the cavity of 
the thorax as the lung that has performed its functions ; nor does it, on 
section, discharge a frothy sanguineous serum like the latter. Atelec- 
tasis is not necessarily fatal ; it is probable that in many instances it is 
entirely overcome, as the child acquires vigor, or that, while a few lobules 
remain in a permanently contracted state, the remainder of the lung 
suffices for the purposes of aeration. We frequently, in adults, meet with 
puckerings of the surface of the lung, without any trace of inflammation, 
which may perhaps be set down to this congenital state of the tissues ; 
or, possibly, the small nodules of fibroid or calcareous matter, which we 
often find equally without appreciable recent lesion to which they could 
be referred, may be due to the same cause, as we know them to favor 
parts in which there is an arrest of development. Dr. West observes 

1 De Pulmonum Vitio Organico, &c, Lips. 1832, and Die Fotuslunge im GebornenKinde. 
Grimma, 1835. 

2 Etymology — ar&\hq, imperfect; «tTa<n?, expansion. 



393 ATELECTASIS PULMONUM. 

that if air be blown into a lung, some lobules of which are not duly ex- 
panded, it will permeate the collapsed air-tubes ; the pulmonary vesicles 
will, by degrees, become distended, and the solid lobules rise to a level 
with the rest of the lung, acquiring the same color and consistence, and, 
like other parts of the organ, will float in water. A single inflation, 
however, is by no means sufficient to render this change permanent; but, 
the moment the tube is withdrawn, the air will escape, and the lobules 
recently distended will again collapse and sink below the rest of the lung; 
their color, too, will become dark, though less so than before. In con- 
junction with imperfect expansion of the lung-tissue, we invariably find 
the foramen ovale and the ductus Botalli still open. The pathology of 
the affection, which we have attributed mainly to a mechanical defect, 
has been explained by French writers, who have termed it carnification, 
as the result of pneumonia ; but, although pneumonia may supervene 
in an atelectatic lung, the characters of the two diseases are sufficiently 
distinct to be discriminated on a careful examination. We meet with a 
condition analogous to infantile atelectasis in advanced age; we find the 
apices of the lungs converted into a dense melanotic mass, in which we 
are unable to trace tubercular deposit, while there is an obliteration of 
the vesicular structure, and apparently also of the bloodvessels. The 
tissues are converted into a viscid, tenacious mass, deprived of all air. 
Under the microscope, we see an almost homogeneous membrane, through 
which the carbonaceous deposit is scattered irregularly, with only here 
and there a trace of the circular fibres of the lung. In the cases which 
have fallen under our own observation, there was a thickened pleura, 
forming a cap over the apex, which must, by its compression, have con- 
tributed much to the obliteration: whether any pneumonia had aided in 
producing the result is doubtful; our impression certainly is against this 
view, the excessive deposit of carbonaceous matter associated with the 
large pleuritic exudation in the confined post-clavicular region of the 
thorax appearing adequate in itself to account for the effect produced. 
Another question is, whether fatty degeneration affecting any of the 
tissues was an element in the process ; possibly, the deposit of carbona- 
ceous matter in excess may be viewed as the result of a process allied 
to fatty degeneration : we have not ourselves observed such an evolution 
of oil as would justify the assumption that the main feature of the dis- 
ease belongs to this class. 

Another form of atelectasis, which Bailly and Legendre first pointed 
out, and which has been well illustrated by Dr. West, is that which 
occurs after respiration has once been fairly established, and is the 
result of an interference with the mechanism of respiration. It is this 
form more particularly which Valleix, and Rilliet, and Barthez, under 
the term of carnification, have attributed to lobular pneumonia; the 
affection being limited to a single lobule or to a cluster, forming a hard, 
compact mass, surrounded by the normal tissue. When the affected 
part is inflated the vesicles distend, and thus show that there is no in- 
flammatory effusion. In a child, whose case is related by Dr. West, 
there was no evidence of disease until the age of nine months, although 
she had not thriven well, and had become pigeon-breasted. She then 
lost flesh rapidly, and began to cough, without having had any previous 



(EDEMA PULMONUM. 399 

catarrh. Her case seemed to be one of bronchial phthisis. Four days 
before death she became suddenly oppressed, and the cough more severe; 
the dyspnoea increased, while the cough became less frequent. A few 
hours before death the lips were quite livid ; she breathed from eighty 
to eighty-six times a minute ; the abdominal muscles acting most vio- 
lently, but the chest being scarcely at all expanded. No tubercle was 
found in any organ after death, but large portions of both lungs pre- 
sented the undilated condition, which disappeared entirely on inflation ; 
the bronchi were pale, and contained very little mucus ; the right side 
of the heart was greatly distended with coagulated blood, which its 
thin, pale, and flaccid substance, had evidently been unequal to propel 
with the requisite vigor. 

There are consecutive conditions of the lungs which may respectively 
be mistaken for emphysema or atelectasis. Thus, after long-standing 
disease of one lung, impairing its functions and diminishing its capacity, 
we find its fellow taking on a vicarious action, and expanding so much 
as to displace adjoining viscera; a point of importance in forming 
diagnoses of diseased states of the thoracic contents. On opening this 
side of the thorax the lung may appear too large for its cavity, and in- 
duce the assumption of an emphysematous condition. The history of 
the case, the examination of the lung, and the shrunken, contracted, 
bound-down, and atrophied condition of its fellow, will determine the 
real nature of the case. Whether in this instance there is an actual 
new formation of pulmonary vesicles, it is difficult to ascertain; Roki- 
tansky is of opinion that such an hypertrophy of the lungs is due to a 
dilatation of the air-cells, with a simultaneous augmentation of their 
tissues; that it does not consist in an increase in the number of the air- 
cells, but in their dilatation, the increased thickness of their walls, the 
enlarged caliber of their walls, and in the development of their vessels. 
There can be no doubt that the changes that take place are intended to 
increase the powers of aeration of one portion of the breathing appa- 
ratus; an increased thickness in the walls of the air- vesicles can scarcely 
facilitate oxygenation, unless it is by a reduplication of the basement 
membrane into the breathing cavity, so as to afford a larger surface for 
the capillaries to ramify upon. The special circumstances under which 
the secondary enlargement and contraction of the lungs take place, will 
be a subject for further consideration at a subsequent page, when we 
come to discuss the pathological states of the pleura. 



(EDEMA PULMONUM. 

Before investigating the inflammatory conditions of the lungs, we are 
required to devote some consideration to a morbid state, which we fre- 
quently meet with in the dead body, and which, since the attention of 
the profession was first especially directed to it by the researches of 
Laennec, 1 has been known by the term of (Edema Pulmonum. It con- 
sists, as its name implies, in a serous infiltration of the interstitial por- 

1 De P Auscultation Mediate, vol. i. p. 349. 



400 PULMONARY CONGESTION. 

tion of the pulmonary parenchyma. It causes a puffiness of the organ, 
which pits more or less on pressure, has lost its natural crepitant sensa- 
tion, and does not collapse when the thorax is opened. The oedematous 
lung is characterized by pallor and anaemia, and when cut into discharges 
an abundance of clear, limpid serum, in which the comparative absence 
of air-bubbles is characteristic. It occurs in connection with, and as a 
result of, a great variety of debilitating diseases, and rarely presents an 
idiopathic character, though it is sometimes observed in this form, and 
may then be termed serous apoplexy of the lungs. Pulmonary oedema 
very commonly supervenes immediately before death; and has been 
attributed to the extinction of the nervous power of the vagi, in conse- 
quence of the experiments of Muller, which have shown that the fatal 
effect of dividing these nerves in the neck, is mainly due to the infiltra- 
tion of the lungs and air-passages with serum. Both lungs are gene- 
rally affected to the same extent, nor is the oedema necessarily confined 
to the posterior portions, even where it is only partial. A peculiar fact, 
remarked by Hasse, is, that where, in general dropsy which proves fatal, 
the one lung is found universally adherent to the pleura, and the other 
not, the former is oedematous, and the latter compressed by hydrothorax. 
Laennec states that pneumonia induces a great proclivity to the pro- 
duction of pulmonary oedema during the period of convalescence; this 
may have been partly due to the excessive depletion formerly in vogue, 
for pulmonary oedema appears to occur so frequently, and so much in 
the ratio of the general anaemia of the individual, that we see no reason 
for assuming a special tendency in one disease to produce it. The lax 
texture of the lungs, like that of the superficial cellular tissue, neces- 
sarily favors a serous effusion under such circumstances. 



PULMONARY CONGESTION. 

This spongy texture of the lungs, coupled with the fact that these 
organs contain a larger quantity of blood, in proportion to their size, 
than any other organ of the body, renders them peculiarly liable to the 
various forms of congestion — a tendency which is enhanced by the re- 
lation existing between the pulmonary and systemic circulation. Most 
of the various causes of death, while inducing an arrest of the circula- 
tion, give rise to an accumulation of blood in the organs of respiration. 
Nysten's experiments have shown, that the contractile power of the 
right side of the heart continues long after the irritability of the left 
side is extinguished ; and the effect of maintaining artificial respiration 
in cases in which death from a lesion of the nervous powers is to be 
apprehended, further demonstrates the great share taken by the lungs 
in the production of death. The elasticity of the arteries also exercises 
some influence in producing an engorgement of the lungs, at the moment 
of, and immediately after death, by propelling their contents into the 
venous system, and thus overcharging the right side of the heart. Nor 
must we forget that, in long-standing debilitating disease, whether a 
specific fever or an adynamic condition, resulting from other disorganiz- 
ing processes, respiration is carried on with little vigor, while the mus- 



PULMONARY CONGESTION. 401 

cular tone is reduced to a low ebb, so tbat both causes conspire to retain 
the blood in the pulmonary tissues. Hence, in estimating the pathologi- 
cal changes in the' lungs connected with the actual disease, to which 
death has been attributed, we must be very careful in distinguishing be- 
tween the effects of the dying and death itself, the secondary products 
of debility and dissolution, from the changes attributable to active dis- 
ease. Both, however, often pass imperceptibly into one another, with 
gradations, which only confirm the view that disease is, in itself, incipient 
death. And though we may lay down rigid classifications of the modes 
of dissolution, and we may occasionally meet with types corresponding to 
our scientific arrangement, still, as Dr. Williams observes, in his admirable 
Principles of Medicine: "In the slower dissolution by which diseases 
generally prove fatal, all functions and structures are more or less in- 
volved, and life in all is dwindled down to so slight a thread, that, when 
it breaks in one, others scarcely retain it long enough to enable us to 
say that death begins distinctly in any part." Still, whether we can 
trace the death to asthenia or apncea, coma or paralysis, the prevailing 
effect is to induce those symptoms to which we have above alluded in 
the lesser circulation. 

It is not within our scope to dwell upon the treatment of disease, but 
we may be allowed to urge these facts as of the utmost importance in 
connection with that department of medicine, inasmuch as they demon- 
strate the necessity of, under all circumstances, attending to the state 
of the pulmonary circulation, and removing all avoidable sources of local 
embarrassment, while we stimulate the general forces to carry the patient 
through the valley of danger to the pleasant heights of recovery and 
health. The congestion which belongs chiefly to the causes first alluded 
to, is most liable to affect the posterior and inferior portions of lungs; 
after death, as in the debility resulting from disease, the blood follows 
the physical law of gravitation, and sinks to the lowest point it can 
gain. If there be no concomitant inflammatory changes, the congested 
portion presents a dark red color, and, though firmer than the more 
bloodless anterior part, still crepitates under the finger, and floats in 
water. The color is almost uniform, and the line of definition between 
the congested and the non-congested portion is tolerably defined. The 
pleural surface of the engorged portion presents a corresponding violet 
tint, which sometimes is more or less circumscribed at single points. 
The depth of the color varies somewhat in different diseases; and in very 
anremic cases, especially in those associated with general dropsy, there 
is more or less serous effusion with the sanguineous congestion. In a 
medico-legal point of view, congestion of the lungs may become a ques- 
tion of life and death; thus, in the recent trial of Mr. Kirwan, in Dublin, 
the conclusion that his wife's death was due to violence, which has since 
been shown to be erroneous by the highest authority in medical juris- 
prudence in this country, Dr. Taylor, 1 was based mainly upon the fact 
of the lungs being congested posteriorly. This was the main fact upon 
which the medical witness, Dr. Hatchett, relied, in proof of death hav- 
ing been brought about by drowning; we know that it may be the result 

1 Dublin Quarterly Journal, Feb. 1853. 

26 



402 . PULMONARY APOPLEXY. 

of post-mortem changes, and, as Dr. Taylor observes, "it is not of the 
least value as medical evidence of drowning, unless observed soon after 
death, and unless attended with other appearances, which, upon the 
assumption of death by drowning, or by some other form of asphyxia, 
ought always to accompany it." 

But recently, a lad was examined at St. Mary's Hospital, who was 
brought in asphyxiated by drowning ; he was, in fact, dead at the time, 
but still some efforts were made to restore him. The post-mortem ex- 
amination showed none of the visible signs commonly attributed to 
drowning, and there was no congestion of any of the viscera. 

It is doubtful whether there are any means of determining whether 
hypostatic congestion has occurred after death or within a few days of 
dissolution. We know that in full vigor the blood is not disobedient to 
the laws of gravitation, as we may easily ascertain by allowing our arm 
to hang down and then raise it into a vertical position, or by elevating 
our feet above our head; therefore, it is not surprising that, in the re- 
cumbent position, as the powers of life fail, the blood should gravitate 
to the posterior portion of the lungs. If the congestion is confined to 
one lung, or to the anterior parts of the lungs, we may safely attribute 
it to morbid processes ; and if there are any other traces of inflammatory 
action, to which we shall advert further on, we may equally set down 
the congestion to a pathological cause. 

Hypostatic congestion is closely allied to the disease which has been 
termed pneumonie des agonisans, by Laennec, and has been fully de- 
scribed by Mr. Erichsen 1 as the congestive pneumonia, to which the 
majority of deaths following capital operations are due. 



PULMONARY APOPLEXY. 

The most formidable phenomenon to which congestion of the lungs 
gives rise, is the disease to which, from the earliest time.s, the term of 
pulmonary apoplexy has been applied. It is distinct from the hemor- 
rhage that occurs from the bronchial mucous membranes, either owing 
to an adynamic state of the blood or to active congestion, both in the 
symptoms it produces during life, as well as in the post-mortem appear- 
ances. The seat of pulmonary apoplexy is the parenchyma of the lung, 
and, most probably, with few exceptions, only the intervesicular tissue, 
for it is rarely associated with haemoptysis, which we should expect if 
the effusion took place into the air-vesicles themselves. The apoplectic 
spot may be felt before the lung is cut into as a globular mass, of greater 
density than the surrounding tissue, and, if near the surface, its darker 
color also attracts attention. On section, we find a dark red, almost 
black, homogeneous, circumscribed spot, varying in size from a pin's 
head to an orange, of the appearance and consistency of damson cheese, 
bounded by tissue, which is comparatively healthy both in color and 
consistency. The only interruption to the uniform color that is met 
with, is that caused by the dividend bronchules, which are less dark 

1 Medico-Chirurgical Transact, vol. xxvi. p. 29. 



PULMONARY APOPLEXY. 403 

than the surrounding parts. The more recent the hemorrhage, the more 
defined the outline ; while, if the patient has survived the immediate 
shock, the margin of the spot fades away, owing to incipient absorption. 
Thus we have seen, as in the patient from whom the accompanying 
drawing was taken, several spots, evidently varying in their date. The 
breathing capacity of the part is entirely destroyed ; it contains no air, 

Fig. 184. 




Pulmonary apoplexy, occurring in a man aged 53. There -were several apoplectic masses, exhibiting a deep 
purple, almost black hue, and causing an homogeneous solid appearance of the part affected, as shown in the 
section. 

and when scraped, only yields a dark, thick, bloody fluid, in which the 
microscope detects nothing but blood-corpuscles and some pulmonary 
debris. If the margins of the clot be scraped and examined, we may 
find exudation corpuscles, varying in size from /^o °f an inch, showing 
that some irritative action and organic change are going on. 

The base of the lungs is the part most commonly affected, and there 
may be one, two, or three isolated apoplectic spots. Laennec, who 
viewed pulmonary apoplexy and haemoptoic engorgement as modifica- 
tions of the same disease, considered haemoptysis as a symptom equally 
of both, and was of opinion that the former not unfrequently terminated 
in resolution and recovery. Without disputing the possibility of the 
absorption of an apoplectic clot, it certainly appears that there is an 
essential distinction between bronchial and parenchymatous hemorrhage, 
which we must explain by a preliminary alteration, as yet not sufficiently 
understood, in the proper lung tissue. This is the more probable when 
we consider that the haemoptysis which is the harbinger and concomitant 
of tubercular disease, rarely, if ever, presents the lesion denominated 
pulmonary apoplexy, and that the latter is frequently met with in the 
dead body without its presence having been manifested by hemorrhage 
during life. Louis 1 states that, during the epidemic yellow fever, which 
occurred in Gibraltar, in 1828, pulmonary apoplexy was very frequently 
found in the victims to the disease, in none of whom haemoptysis had 
taken place ; on the other hand, he had never, in phthisical patients who 
had died during, or shortly after, attacks of haemoptysis, met with ap- 

1 Researches on Phthisis, Syd. Soc. Ed. p. 168. 



404: PULMONARY APOPLEXY. 

pearances resembling those of pulmonary apoplexy. We are, therefore, 
in every way justified in looking upon the two affections as essentially 
distinct from one another. 

Pulmonary apoplexy occasionally gives rise to hemorrhage into the 
pleural sac, from a laceration occurring in the pleura; this will probably 
be owing to the same process of disintegration, which permitted the 
apoplectic effusion in the first instance. 

The interstitial form of pulmonary hemorrhage may be due to various 
predisposing causes, that affect the constitution of the blood, or of the 
tissues, or both together ; while the exciting cause is most commonly to 
be found in a morbid condition of the heart and great vessels, and more 
particularly in hypertrophy of the right ventricle. About two-thirds of 
the cases on record have exhibited some lesion of this kind ; still, as 
Hasse very justly remarks, a preternatural condition of the pulmonary 
texture appears always to precede, while a chemical analysis of the blood 
would probably exhibit a scorbutic diathesis or an hydraemic character. 
It has been observed that drunkards are prone to be affected with pul- 
monary apoplexy. 

The secondary processes to which apoplectic spots of the lungs are 
subject are, a gradual absorption of the blood effused, suppuration and 
abscess, or isolation by the formation of a cyst ; none of these processes, 
however, extend far, and with regard to the last, no satisfactory proof 
is extant of its occurring at all, beyond an imperfect observation by 
Bouillaud. 1 

1 Archives Gene'rales de Medecine, vol. xii. p. 399. 



CHAPTER XXIX. 

PNEUMONIA. 

Inflammation of the pulmonary tissue is commonly assumed to pre- 
sent three stages, which we may trace in regular succession in the patient, 
or which we find coexisting at various portions of the lungs in the same 
dead subject. The first stage, that of congestion, we have already con- 
sidered ; its situation, its effect upon the cohesion of the tissues, the co- 
existence of other inflammatory changes, and the history of the case 
must assist us in determining its character, though it is often difficult to 
be certain of its nature. The general effect of acute inflammation, in 
altering the cohesion of the tissues, is a point of considerable importance ; 
it particularly affects, as Sir Robert Carswell has pointed out, the uniting 
cellular element, and may thus demonstrate the previous existence of 
inflammation, though the redness and vascularity have disappeared, or 
but faintly mark the degree of alteration which the disease has effected 
in the process of nutrition. This general law is compatible with the 
observation that the second stage of pneumonia, or hepatization, is 
accompanied by a state of solidification ; for, as the first-named author 
remarks, though the tissues feel harder than natural when compressed, 
the diminution of cohesion which has taken place between their ana- 
tomical elements is rendered conspicuous by the facility with which they 
are penetrated, broken down, or crushed. 

In doubtful cases the microscope would aid us, by determining the 
presence or absence, in 1 the congested portion, of exudation-corpuscles, 
which we find where the naked eye fails in distinguishing the existence 
of inflammation, and which, at all events, show that some organic meta- 
morphosis of the vital fluids is taking place, not consistent with the 
ordinary physiological changes. The confines of the first and second 
stages merge into one another, and are often difficult to define. In 
the second, the stasis of the blood becomes more marked, the specific 
gravity of the pulmonary tissue increases, the overcharged vessels relieve 
themselves by fibrinous exudation into the interstitial tissue, and by slight 
hemorrhage into the air-vessels, which, mingling with the bronchial secre- 
tions, gives rise to the pathognomonic rust-colored expectoration of pneu- 
monia. This stage has received the name of hepatization, owing to the 
increased density of the parenchyma causing the affected portion of the 
lungs to resemble a piece of liver. M. Andral, who considers the soft- 
ening process to predominate, prefers the term ramollissement rouge, as 
applied to this condition. It is well to remember that both designations 
are used indiscriminately for the same morbid condition. 



406 PNEUMONIA. 

The color of the affected part is of a dark red, which is more or less 
venous or dusky, in proportion to the type of the inflammation ; the 
crepitant character of the tissue is fast disappearing ; the lung, on sec- 
tion, has lost that light spongy appearance peculiar to it in health, and 

Fig. 185. 




Lung in a state of red hepatization; the air-cells are filled with corpuscular fibrin or exudation-matter, and 
are surrounded by enlarged and congested vessels. Magnified twenty diameters. (Bayle's Granulations.) 
From a man ast. 66, who had double pneumonia. 

but little frothy red fluid exudes from it. On the pleural surface, instead 
of the slate-colored, marbly hue of the normal state, we find a more 
uniform, dusky-red color, scarcely broken by the interlocular septa. At 
this period, as Gendrin first pointed out, repeated washing and continued 
maceration fails to restore the natural color of the tissues, which they 
recover, under such a process, if the redness is due merely to congestion. 
Before that exudation and general infiltration have taken place, which 
constitute the succeeding stage of pneumonia, we find that, on breaking 
up a portion of hepatized lung, the surface is studded with small pinky 
granulations, which are identical with the pulmonary granulations of 
Bayle. This author, and some of his successors, looked upon them as 
the first stage of tubercular disease ; but, as Andral has satisfactorily 
shown, they are a product of inflammation, and must be considered as 
an agglomeration of a few hyperaemic vesicles. 

Though the specific gravity of the hepatized lung is considerably in- 
creased, the dimensions of the organ are not necessarily augmented ; 
occasionally, however, the organ is shown to be enlarged by the inden- 
tations left on its surface by the ribs. 

In the present state of our knowledge of inflammatory processes 
generally, and of the form which they assume in the lungs especially, 
it is impossible, with certainty, to show the minute changes which take 
place in this stage of pneumonia. That the parietes of the pulmonary 
vesicles should themselves thicken, consisting as they do of basement- 
membrane only, is, at least, not proved, and, though given on the ex- 
alted authority of Andral, he fails to state the actual grounds for the 
view which he takes. That some change occurs in the solids as well as 
the fluids of the inflamed part, that the chemical and physical proper- 
ties of both undergo an alteration, that their mutual affinities differ from 
those of health, is manifest from the phenomena of disease, but the 
ultima ratio yet remains to be discovered. Andral's theory of the pul- 
monary granulations being due to injection and tumefaction of the 



PNEUMONIA. 407 

parietes of the air-vesicles, is not consonant either with theory or ob- 
servation ; for it is not difficult to trace the deposit within a cavity, nor 
is it intelligible, without actual demonstration, how swelling of a mem- 
brane could produce such uniform nodules without any anatomical reason 
to assign for such regularity. We regard the second stage of pneu- 
monia, that of red hepatization, as a perpetuation of the congestive 
stage, with incipient exudation into the parts surrounding the vessels of 
the albuminous constituents of the blood; the exudation takes place 
both into the interstitial and into the inter-vascular spaces, according 
to the laws regulating the exosmosis of inflamed vessels; the microscope 
exhibits a vast congeries of gorged vessels permeating the pulmonary 
structure and surrounding the air-vesicles; while the exuded fluid show3 
a granular blastema, blood-corpuscles, and exudation-cells, which are, 
probably, of an oily or albuminous character. 

These exudation-cells, here, as elsewhere, are the product of organic 
or bio-chemical changes, and not, as Hasse 1 would seem to imply, the 
mere effect of chemical agents applied on the table of the microscope. 
They can be traced in the various stages of formation from the granular 
corpuscles to the agglomerate corpuscle and the perfect cell immediately 
on removal of the fluid from the body; and their character is essentially 
the same, as we have elsewhere shown, in the most various situations. 

The different degrees of congestion of the inflamed portion produce 
a mottling of the surface; the congestion itself may be circumscribed 
with a definite line, or it fades off gradually into the healthy tissue. 
As the second stage progresses, marbling of a different kind occurs, 
which is due to the gradual disappearance of the coloring particles of 
the blood, the absorption of the blood itself, and the substitution of a 
fibrinous deposit, or pus. We now enter into the third stage of pneu- 
monia, or that of gray hepatization. The term well denotes the ap- 
pearance of the affected portion ; it is entirely consolidated and deprived 
of all air ; it presents a grayish or grayish-yellow color, which is only 
varied by the almost linear remains of the compressed bronchules, and 
the pigmentary matter scattered through the lung tissue. The general 
condensation of the tissues necessarily, also, 
involves the bloodvessels, and arrests and Fig. 186. 

prevents the circulation ; so that the fur- 
ther changes must be mainly due to extra- 
vascular metamorphoses. The parenchyma 
becomes gradually softer, and the more 
straw-colored and paler its hue, the more 
fully the suppuration process is established, 
and the more friable the tissue becomes. 

A purulent fluid nOW exudes On pressure. Microscopic characters of the contents 

At the commencement of this stage the air- of an ™ cle * *»* hepatization, 

. , «=• consisting of granular matter, pus-cor- 

VeSldeS may be isolated m the Shape Of puscles", exudation^ells, and cylindrical 

gray granulations, of a globular form, con- epithelium. 

taining an opaque granular matter. The 

microscopic characters of gray hepatization, at this period, have erro- 

1 Pathological Anatomy, Syd. Soc. Ed. p. 211. 




408 PNEUMONIA. 

neously been stated to "be those of suppuration only; but true pus-cells 
are by no means the predominant forms seen under the microscope; the 
corpuscles that we have found to prevail were much larger than pus- 
cells, varying from 5-/^ to 5^ of an inch, presenting a sharp out- 
line, and containing one or more glistening granules or globules, re- 
sembling oil. These are seen surrounded by a granular stroma, which 
also contains pus-corpuscles, free oil, cylindrical epithelium, and some 
forms resembling fibroid cells. The great rarity of actual abscess 
occurring in the lungs, compared with the frequency with which pneu- 
monia reaches its third stage, would alone indicate, that this part of the 
process does not consist simply in suppuration ; and we would explain it 
by the double exudation, which takes place into the vesicles and into the 
interstitial spaces, the one continuing somewhat, though remotely, under 
the influence of the atmosphere, the other being entirely beyond its 
action. The condensation that takes place in the tissues in pneumonia, 
and the form of the deposit, is of a very different character from that 
occurring in tubercular disease, and would alone serve to prove that the 
exudation takes place both within and external to the air-vesicles. The 
consolidation of pneumonia does not produce any material change in 
the form of the vesicular structure, which continues to present its glo- 
bular form even in the third stage; now, if the exudation took place 
exclusively within the vesicles, their mutual compression would produce 
polyhedral forms, while the exclusive effusion external to them would 
not only obliterate them, but entirely destroy all trace of them ; as it 
is, we continue to trace their form, because the extra and intra-vesicu- 
lar effusions being tolerably uniform, the pressure is equable, and no 
material alteration in the form of the air-cells takes place. This is not 
the case, as we shall see, in tubercle, where the effusion is limited to the 
intra-vesicular spaces. 

When the third stage of pneumonia advances to a fusion of the inter- 
vesicular septa, and an entire breaking down of the tissues, all trace of 
the normal structures disappears, and we only find a confused mass of 
pulmonary debris, pus, and ichorous sanies. We then have to deal with 
genuine pulmonary abscess. 

The parts most liable to idiopathic pneumonia are the inferior portions 
of the lungs, while the upper lobes and apices of the lungs are rarely 
affected with pneumonia, except in connection with tubercle. Louis 
states that he has constantly found pneumonia affecting the upper and 
anterior part of the lungs, without a trace of the disease existing pos- 
teriorly, to be tuberculous; and he lays it down as a rule that this 
localization of pneumonia may lead to the diagnosis of tubercular disease 
previously undiscovered. This is undoubtedly correct in the main, but 
as Dr. Watson observes, it is probably exnggerated ; and exceptions to 
the rule, regarding pneumonia, are met with, as well as in reference to 
the ordinary site of tubercle. Indeed, the numbers given by Andral 
would almost destroy the validity of the law altogether ; for though they 
yield the preponderance to the lower lobes, they seem to show a much 
greater proclivity in the upper than they are commonly supposed to 
possess; in eighty-eight cases of pneumonia, he found it limited to the 



PNEUMONIA. 409 

lower lobes in forty-seven ; in thirty in the upper lobes, and in eleven 
the entire organ was inflamed. 

The general tendency of pneumonia is to spread from below upwards; 
and for this reason we commonly meet with the several stages in the 
same lung ; the base to a greater or less extent presenting the gray 
hepatization — red hepatization affecting the adjoining portion next above 
the former — while the upper lobe offers more or less pneumonic conges- 
tion. The smaller bronchi of the affected part are not, as has been 
stated by several authors, invariably affected at the same time ; we often 
see them meandering, as white rivulets, through the inflammatory mass; 
and they occasionally appear to possess a repellent power, and to form 
a line of demarcation between two parts that are unequally affected. A 
curious exception is mentioned by Rokitansky, in which, owing to bygone 
pleuritic effusion, the base of the right lung had not recovered its pris- 
tine elasticity, and where the entire lung was in a state of red hepatiza- 
tion, with the exception of the apex, the anterior margin, and the base, 
which latter is scarcely ever found exempt. It is equally exceptional 
to find pneumonia limited to the central portion of the lungs, though 
such cases undoubtedly occur ; hence, one of the most ordinary compli- 
cations of the disease is with pleurisy ; for which reason some authors 
prefer the compound term pleuro-pneumonia, to the separate names 
pleuritis and pneumonia. 

According to the unanimous testimony of all observers, the right lung 
is more frequently affected than the left, while double pneumonia is less 
often met with than either; the analysis of two hundred and ten c,ases 
of pneumonia by Andral, 1 yielded the following results : — 

The right lung alone was the seat in . . . . . .121 

The left do. do 58 

Both together do. do. 25 

The seat undetermined in 6 

Total 210 

The relation is somewhat, though not essentially, altered by the larger 
numbers collected by Sir John Forbes; he finds that in 1131 cases — 

The right lung was affected in 562 

The left in 333 

And both together in 236 

The pneumonia, as we have described it, is the form which has re- 
ceived the name of lobar pneumonia, as affecting entire lobes, in contra- 
distinction to the lobular form of pneumonia, in which it' is limited to 
individual lobules scattered through the healthy lung tissue. It is, in 
fact, a partial pneumonia, which, from some unknown cause, does not 
spread beyond the point of primary lesion. Small spots, with a scal- 
loped outline, presenting the various stages of congestion, of red and of 
gray hepatization, are found on section scattered indiscriminately 
through the organ. It is peculiar to infant life, and is probably con- 
nected with the same imperfect development of the vesicular tissues, 
which we have already found to constitute an important disease of early 

1 Clinique Medicale, vol. iii. p. 470. 



410 PNEUMONIA. 

childhood. In many instances there is no doubt that the two conditions 
have been confounded. This cannot, however, be the case when we find 
the lining studded with small, yellow spots, satisfactorily indicating the 
third stage of pneumonia. Thus, in a child of one year and a half old, 
which was under our own observation, and from his ninth month had 
been subject to repeated attacks of broncho-pneumonia, we found the 
whole of both lungs studded with small purulent deposits ; on the left 
side, where the softening process was furthest advanced, pus readily 
exuded on pressure ; there were no cavities, nor was any tubercle dis- 
covered. The latter point, the absence of tubercle, is one of import- 
ance in determining that these purulent accumulations are not vomicae, 
but due to a simple inflammatory process, independently of other cha- 
racters that mark tubercle. The disease is stated by writers to result 
from phlebitis, accidents, and operations ; but we shall have occasion 
to see that secondary abscesses and the form of pneumonia peculiar to 
individuals who have been operated upon, diiFer materially from lobular 
pneumonia. 

According to Rokitansky, the character of ordinary pneumonia is 
essentially allied to croup, on the ground that the exudation takes place 
into the air-cells, and not into the interstitial tissue ; this author dis- 
tinguishes -two forms of exudation in pneumonia, the one taking place 
into the cavity of the vesicles, the other interstitial. This classification 
is not borne out by what we see in the dead subject ; and we are of 
opinion that the inflammatory effusion takes place into both at the same 
time. Our means of analysis are scarcely sufficiently advanced at 
present to determine whether it predominates in one or the other occa- 
sionally. Moreover, the character of croup is so peculiar, and the term 
generally understood to be applied to a form of inflammation of certain 
mucous membranes, so distinct from the inflammatory processes to which 
they are ordinarily exposed, that we are only likely to produce confusion 
by applying it to processes which, theoretically, we may consider allied 
to it. In the present instance there is not, however, even any theo- 
retical presumption in favor of Rokitansky's view, for there is no rela- 
tion between the occurrence of pneumonia and angina membranacea ; the 
latter is essentially a disease of childhood, the former is the property of 
all ages ; a peculiar habit tends to produce the one, certain seasons and 
places also create the proclivit} 7 to it ; while in the other, inflammation 
of lungs, we do not trace the agency of the same influences. The de- 
scription of the minute changes recurring in pneumonic exudation, which 
we have given, also tends to disprove the existence of an analogy, much 
less an identity, between the two processes. 

The varieties of pneumonia which are spoken of by authors, as differ- 
ing from ordinary acute pneumonia, are all characterized by presenting 
a more asthenic and less acute type, "than the ordinary form which we 
have just discussed. The hypostatic pneumonia of Piorry, typhoid 
pneumonia, congestive pneumonia, the bilious, and the erysipelatous 
form of Riverius, and older writers, the senile pneumonia described by 
Hourmann and Dechambre, are all forms of asthenic pneumonia, occur- 
ring in subjects debilitated by other diseases, in whom the lungs are 
attacked by a low, creeping, sneaking inflammation. The congestion 



PNEUMONIA. 411 

is of a more venous character, causing a dusky brownish violet tint ; 
the physical law of gravitation exerts a strong influence upon the blood 
in the thorax, and the posterior portions are predominantly affected ; 

Fig. 187. 




Pleural surface of a portion of splenified luug, affected with typhoid pneumonia, from a female set. 25, who 
died of typhoid fever. The lung closely resembled the spleen in consistency, was of a brownish red hue, in- 
terspersed with deep purple spots of an apoplectic character. 

the tissues are more friable and lacerable even in the first stages, and 
in the progress of the disease we fail to find that evidence of plastic 
inflammation which accompanies ordinary sthenic pneumonia. Much 
yet remains to be done with regard to determining the actual morbific 
agent in many of the forms of disease with which we have to deal ; and 
when we shall have arrived at a correct appreciation of the erases, 
which induce the palpable manifestations of inflammatory action, we 
may hope to reconcile theory and practice more fully than has yet been 
done ; we may then also explain why such various modes of treatment 
are successful in combating symptoms, which, to our short-sighted vision, 
indicate the same disease, though in reality they are due to totally 
different causes. Thus, pneumonia, occurring in a system in which 
there is a predominance of lactic or lithic acid, would necessarily de- 
mand different remedies from one in which an alkaline or septic principle 
prevails. But to return to our legitimate sphere : the hypostatic form of 
pneumonia occurs in a variety of diseases, in which the patient is con- 
fined to the recumbent posture, and in which the system is much debili- 
tated. Under the name of congestive pneumonia, it has been described 
by Mr. Erichsen as the most fertile source of the fatal issue of capital 
operations, after the patient has survived the first shock, and therefore 
calls for the special attention of the operating surgeon. 

In this form, the congestion is by far the most prominent symptom ; 
and though enough of vitality remains to give rise to some active symp- 
toms, yet the debility of the patient, and of the organs of respiration, 
is so great as to prevent a reaction of a vigorous character. Mr. Erichsen 1 
has analyzed sixty-two post mortems of individuals who died after ope- 
rations, and has set down as pneumonic only those cases in which either 
one lung alone was affected, or else, in which some other palpable sign 
of inflammatory action was manifested in the cavity of the thorax, beyond 
a merely congested or softened condition of these organs, such as solidi- 

1 Medic o-Chirurg. Transact, vol. xxvi. p. 29. 



412 ABSCESS. 

fication of their tissue, whether hepatization or splenification of it, the 
effusion of recent lymph or serum into the pleural sacs, or marked evi- 
dences of inflammation of the bronchial mucous membrane. The result 
of his analysis is as follows : There were twenty-eight in which there 
were evident signs of pneumonia; eleven in which the lungs presented 
the characters common to the first stage of pneumonia and passive con- 
gestion ; nine where the lungs were diseased, but neither inflamed nor 
congested; and fourteen in which these organs were healthy, though 
many may have presented cadaveric congestion. A fact connected with 
this form of pneumonia, and pointed out by Mr. Erichsen, is, that while, 
in ordinary sthenic pneumonia, the right lung is most frequently affected, 
the left next, and lastly, both organs conjointly, here, the two lungs are 
most frequently affected together. In the twenty-eight cases in which 
pneumonia was traced, the right lung alone was affected three times, the 
left lung alone also three times; and both lungs together, though not 
to the same degree, in twenty-two cases. 

In the pneumonia accompanying typhus, congestion is equally a pre- 
dominant symptom, and requires the more to be carefully watched during 
life, as the insensibility of the patient and the general torpor of the 
nervous system allow it to run its course without producing (in many 
cases) any symptoms of inflammatory action beyond those obtained by 
the stethoscope. Cough, expectoration, and dyspnoea, may be absent, 
while we find extensive crepitation over a large extent of surface. In 
addition to the post-mortem appearances already detailed, we find the 
affected parts very soft, and the product is of an aplastic, jelly-like 
character, while there is no definite limitation to the disease. In some 
cases of atypic pneumonia, where we have reason to suspect an arrested 
secretion of bile in the liver, we find a genuine jaundice of other viscera, 
and then the frothy juice exuding from the cut surface of the pneumonic 
lung may present a yellow tinge, which has probably given rise to the 
term of bilious pneumonia. Again, in senile pneumonia, 1 the follow- 
ing varieties are described as belonging to the second stage; the lung, 
on incision, appears perfectly smooth and homogeneous, discharging a 
reddish, frothless serum, the inflammation occurring in patches, which are 
elastic, or soft; or, if granulations are present, they are much larger than 
in younger individuals. In the third stage, a peculiarity has been occa- 
sionally observed by Hourmann and Dechambre, which Hasse confirms; 
it consists in the purulent matter being sharply defined in spots of from 
one to two lines in diameter, which prove to be the irregularly dilated 
air-cells, often met with at intervals throughout the lungs of aged persons. 



ABSCESS. 

We have already seen that the formation of abscesses, such as we 
meet with in other organs and on the surface of the body, is rarely 
found in the lungs, notwithstanding the frequency with which inflam- 
mation attacks them. Yet a suppurative destruction of the tissue occa- 

1 See Hasse's Pathological Anatomy, p. 229. 



METASTATIC ABSCESSES. 413 

sionally leads to this result, and we then find a cavity varying in size 
from that of a marble to that of an entire lobe, and presenting ragged 
parietes; it contains pulmonary debris and pus, which partially infiltrates 
the adjoining tissues, as there is no lining membrane; or the abscess may 
have discharged its contents, and we then only meet with the irregular 
excavations with jagged walls. Formerly, the frequency of pulmonary 
abscess was considered to be much greater than we now know it to be, 
because tubercular cavities were confounded with this lesion. Now that 
the nature of both affections is better understood, the error is less likely 
to arise; when we are in doubt, the history of the case, the situation of 
the abscess, the condition of the surrounding parts, the presence or 
absence of tubercular deposits in the lungs, are points that will aid us 
in establishing a correct opinion. Carswell has very justly remarked 
that the mere presence of pus must be carefully distinguished from sup- 
puration. In the latter case, we have to deal with an active process, in 
which the tissues and bloodvessels of the part in which we find the pus 
are primarily engaged, or with suppurative inflammation; the process 
which John Hunter conclusively showed to be analogous to secretion. 
In the former, the pus is a foreign body in the blood, and may be con- 
veyed to the seat of disease by the vascular channels from elsewhere, 
or be developed from the constituents of the vascular current within the 
vessels, and subsequently be discharged from them; a process more allied 
to chemical decomposition than to secretion. 



METASTATIC ABSCESSES. 

The mere presence of pus in the lungs, simulating abscesses, and, from 
the cause to which they are attributed, termed metastatic abscesses, or 
purulent deposits, constitutes a pathological phenomenon, which occurs 
more frequently in the lungs than the other parenchymatous viscera. 
This is quite in accordance with the known relation existing between 
phlebitis and the formation of secondary deposits ; the lungs, as the 
receptacles of the entire mass of the venous blood, might therefore be 
expected to exhibit a peculiar liability to any morbid affection connected 
with this portion of the circulating system, a point of great importance 
in reference to the subject immediately under our consideration, as well 
as to other pulmonary diseases. The appearances by which we recog- 
nize these deposits are, spots of yellow pus, varying in size from a pin's 
head to a walnut, generally situated near the surface of the organ, and 
surrounded by a defined patch of deeply-congested tissue, which may 
present a color approaching to black ; beyond this, the parenchyma is 
in a healthy condition, or, at all events, in a state totally distinct from 
the circumscribed disease. We generally find several of these abscesses 
in various parts of the lungs. The pulmonary tissue of the seat of the 
abscess may have entirely disappeared, or we may be yet able to squeeze 
out the pus, so as to show the normal structure. 

Secondary abscesses in the lungs are almost invariably accompanied 
by similar deposits in one or several other viscera, and more especially 



412 ABSCESS. 

fication of their tissue, whether hepatization or splenification of it, the 
effusion of recent lymph or serum into the pleural sacs, or marked evi- 
dences of inflammation of the bronchial mucous membrane. The result 
of his analysis is as follows: There were twenty-eight in which there 
were evident signs of pneumonia; eleven in which the lungs presented 
the characters common to the first stage of pneumonia and passive con- 
gestion ; nine where the lungs were diseased, but neither inflamed nor 
congested; and fourteen in which these organs were healthy, though 
many may have presented cadaveric congestion. A fact connected with 
this form of pneumonia, and pointed out by Mr. Erichsen, is, that while, 
in ordinary sthenic pneumonia, the right lung is most frequently affected, 
the left next, and lastly, both organs conjointly, here, the two lungs are 
most frequently affected together. In the twenty-eight cases in which 
pneumonia was traced, the right lung alone was affected three times, the 
left lung alone also three times; and both lungs together, though not 
to the same degree, in twenty-two cases. 

In the pneumonia accompanying typhus, congestion is equally a pre- 
dominant symptom, and requires the more to be carefully watched during 
life, as the insensibility of the patient and the general torpor of the 
nervous system allow it to run its course without producing (in many 
cases) any symptoms of inflammatory action beyond those obtained by 
the stethoscope. Cough, expectoration, and dyspnoea, may be absent, 
while we find extensive crepitation over a large extent of surface. In 
addition to the post-mortem appearances already detailed, we find the 
affected parts very soft, and the product is of an aplastic, jelly-like 
character, while there is no definite limitation to the disease. In some 
cases of atypic pneumonia, where we have reason to suspect an arrested 
secretion of bile in the liver, we find a genuine jaundice of other viscera, 
and then the frothy juice exuding from the cut surface of the pneumonic 
lung may present a yellow tinge, which has probably given rise to the 
term of bilious pneumonia. Again, in senile pneumonia, 1 the follow- 
ing varieties are described as belonging to the second stage; the lung, 
on incision, appears perfectly smooth and homogeneous, discharging a 
reddish, frothless serum, the inflammation occurring in patches, which are 
elastic, or soft; or, if granulations are present, they are much larger than 
in younger individuals. In the third stage, a peculiarity has been occa- 
sionally observed by Hourmann and Dechambre, which Hasse confirms; 
it consists in the purulent matter being sharply defined in spots of from 
one to two lines in diameter, which prove to be the irregularly dilated 
air-cells, often met with at intervals throughout the lungs of aged persons. 



ABSCESS. 

We have already seen that the formation of abscesses, such as we 
meet with in other organs and on the surface of the body, is rarely 
found in the lungs, notwithstanding the frequency with which inflam- 
mation attacks them. Yet a suppurative destruction of the tissue occa- 

1 See Hasse's Pathological Anatomy, p. 229. 



METASTATIC ABSCESSES. 413 

sionally leads to this result, and we then find a cavity varying in size 
from that of a marble to that of an entire lobe, and presenting ragged 
parietes; it contains pulmonary debris and pus, which partially infiltrates 
the adjoining tissues, as there is no lining membrane; or the abscess may 
have discharged its contents, and we then only meet with the irregular 
excavations with jagged walls. Formerly, the frequency of pulmonary 
abscess was considered to be much greater than we now know it to be, 
because tubercular cavities were confounded with this lesion. Now that 
the nature of both affections is better understood, the error is less likely 
to arise; when we are in doubt, the history of the case, the situation of 
the abscess, the condition of the surrounding parts, the presence or 
absence of tubercular deposits in the lungs, are points that will aid us 
in establishing a correct opinion. Carswell has very justly remarked 
that the mere presence of pus must be carefully distinguished from sup- 
puration. In the latter case, we have to deal with an active process, in 
which the tissues and bloodvessels of the part in which we find the pus 
are primarily engaged, or with suppurative inflammation; the process 
which John Hunter conclusively showed to be analogous to secretion. 
In the former, the pus is a foreign body in the blood, and may be con- 
veyed to the seat of disease by the vascular channels from elsewhere, 
or be developed from the constituents of the vascular current within the 
vessels, and subsequently be discharged from them; a process more allied 
to chemical decomposition than to secretion. 



METASTATIC ABSCESSES. 

The mere presence of pus in the lungs, simulating abscesses, and, from 
the cause to which they are attributed, termed metastatic abscesses, or 
purulent deposits, constitutes a pathological phenomenon, which occurs 
more frequently in the lungs than the other parenchymatous viscera. 
This is quite in accordance with the known relation existing between 
phlebitis and the formation of secondary deposits ; the lungs, as the 
receptacles of the entire mass of the venous blood, might therefore be 
expected to exhibit a peculiar liability to any morbid affection connected 
with this portion of the circulating system, a point of great importance 
in reference to the subject immediately under our consideration, as well 
as to other pulmonary diseases. The appearances by which we recog- 
nize these deposits are, spots of yellow pus, varying in size from a pin's 
head to a walnut, generally situated near the surface of the organ, and 
surrounded by a defined patch of deeply-congested tissue, which may 
present a color approaching to black ; beyond this, the parenchyma is 
in a healthy condition, or, at all events, in a state totally distinct from 
the circumscribed disease. We generally find several of these abscesses 
in various parts of the lungs. The pulmonary tissue of the seat of the 
abscess may have entirely disappeared, or we may be yet able to squeeze 
out the pus, so as to show the normal structure. 

Secondary abscesses in the lungs are almost invariably accompanied 
by similar deposits in one or several other viscera, and more especially 



414 FIBRINOUS DEPOSITS. 

in that one -which, as a depurator of the venous blood, is second in im- 
portance only to the lungs — the liver. 

The universal concomitant of these abscesses is now well ascertained 
to be the suppuration of some distant part or organ, which induces 
phlebitis at the seat of primary injury. This may be the uterus after 
delivery, periostitis of the leg, fistula in ano, psoas abscess, or any other 
similar affection. The system must be in an ataxic condition to permit 
of the poisoning of the circulating current, and, though the introduction 
of pus into the blood is proved to be necessarily fatal, it is probable 
that the local injury would not give rise to phlebitis, unless a peculiar 
predisposition to it existed. Another question is, whether, after the 
occurrence of local phlebitis, the pus is necessarily conveyed from the 
part to each point that afterwards shows a secondary abscess, or whether 
a catalytic effect is produced on the blood, in consequence of what the 
older authors called a purulent diathesis. It certainly does not appear 
that the secondary local effects are a necessary consequence of purulent 
infection; but that this may prove fatal without producing them. M. 
Lebert gives two instances in which he noted the absence of metastatic 
abscesses, notwithstanding manifest purulent infection. 



FIBRINOUS DEPOSITS, 

We occasionally meet with deposits of a different character in the 
lungs, which Rokitansky appears to regard as identical with the puru- 
lent deposits just considered; but which certainly present different 
characters, and are connected with a different state of the system, un- 
less, indeed, we adopt the view that pus and fibrin are essentially the 
same. These deposits occur in a more or less wedge-shaped form, with 
the base towards the pleura, near the surface of the lung. They pre- 
sent a light red or yellowish white color, surrounded by somewhat con- 
gested crepitant tissue, with a defined margin. The lung tissue is in a 
state of disruption, and the microscope exhibits the pulmonary debris 
in a granular stroma, in which granulated nuclei, varying much in size 
and shape, and some highly refracting globules of oil, are seen. The 
color, the consistency, the appearance of the tissue immediately sur- 
rounding these fibrinous deposits, as well as their microscopic charac- 
ters, establish so many points of difference between them and purulent 
deposits, that we are scarcely justified in classing them together, espe- 
cially as we do not observe that the two morbid products occur together 
in the same individual. Nothing can be more valuable than a simplifi- 
cation of the elements of disease, and the demonstration of the real 
identity of apparently different forms ; at the same time nothing is 
more liable to lead us from the path of legitimate induction than hasty 
generalization. With regard to the origin of these deposits, we are 
inclined to regard them as an exudation from the capillary circulation, 
rather than as a result of fibrin being detached at distant points of the 
circulation, and carried by the current into the pulmonary parenchyma. 



GANGRENE — CHRONIC PNEUMONIA. 415 



GANGRENE. 

The most marked form which septic disease assumes in the lungs is 
presented in cases of gangrene; it is, as Dr. Watson observes, very 
seldom the result of acute inflammation, and is almost as uncommon as 
the formation of true abscess. It appears to be due to a peculiar con- 
stitution of the blood, or to a specific poison. Dr. Stokes has published 
some cases in all of which the patients had been habitual drunkards; 
the abuse of spirituous liquors does not, however, seem to exert a uni- 
form influence in it's production ; for, in chronic alcoholism, as described 
by Dr. Huss, 1 this lesion has not been met with. It is also remarkable 
that ergotism, which has a peculiar tendency to induce superficial gan- 
grene, is not accompanied by pulmonary sphacelus. The same applies 
to the analogous disease spedalskhed, 2 or the Norwegian leprosy. It 
presents two forms, the diffuse and the circumscribed. In the former, 
the lung tissue that is involved is broken up into shreds, which hang 
into a cavity filled with a fetid, purilaginous, discolored sanies, and 
through which the bronchi and vessels may yet be traced entire. The 
gangrenous portion presents a variety of hues, in the different shades of 
green, brown, and black. The surrounding parenchyma is infiltrated 
with ill-conditioned pus. An entire lobe, or even the greater portion 
of one lung, is found to be in this condition ; though the upper lobe 
appears to be most prone to the affection. In circumscribed gangrene, 
which is more frequent than the former, we find one or more patches, 
varying in size and of irregular form, scattered through the luKgs. 
There is much less tendency to involve the adjacent parts, and the course 
of the affection is more chronic than the former. Laennec describes the 
color of the mortified portion as black, with a greenish tinge — the texture 
as moister and more compact than that of the lung, and its aspect 
closely corresponding to an eschar, produced upon the cutaneous surface 
by nitrate of silver. The neighboring pulmonary tissue is in a state of 
inflammatory congestion; and, after the sphacelated spot has become 
detached, a false membrane, of a grayish, dirty-yellow color is formed, 
which secretes an ill-conditioned pus. At times, the membrane is formed 
even before the entire separation has been effected. If the gangrene 
involves the pleura, rupture and discharge into the pleural sac may 
ensue, or otherwise the bronchi may be the channels by which the evacu- 
ation is effected. 

CHRONIC PNEUMONIA. 

The existence of chronic pneumonia has been disputed by some 
authors; but both at the bedside, as well as in the dead-house, we find 
cases to which no other name can be given, though, in the present state 
of our knowledge, it is often difficult to define the exact limits of the 
acute and chronic forms. Another difficulty which has yet to be re- 
moved, in regard to this subject is, to determine whether chronic pneu- 

1 See Dr. Huss'sWork on the subject; Alcoholismus Chronicus, &c, Stockholm, 1849. 

2 Dr. Daniellsen and Boeck, Om Spedalskhed, &c. Christiania, 1847. 



416 CHKONIC PNEUMONIA. 

monia is essentially different from the intercurrent pneumonia associated 
with tubercular phthisis, and if so, whether there are any marked cha- 
racters by which in the dead body, where we only have to consider it at 
present, it can be recognized. Andral, who looks upon it as a frequent 
idiopathic affection of the upper lobes, and as that form of pneumonia 
which, from this circumstance, has not met with the proper attention, 
differs materially from the views promulgated by Hasse, and those who 
look upon chronic inflammation of the lungs as essentially connected 
with the tubercular cachexia. 

The chief feature in chronic pneumonia, which we find equally dwelt 
upon by almost all observers, is the hypertrophy of the intervesicular 
tissues, owing, probably, to a deposit of an albuminous character in them, 
llokitansky, in contradistinction to his croupous form of pneumonia, 
gives the name of interstitial pneumonia to a second form, which he re- 
gards as identical with the chronic form of other pathologists, as, for 
instance, Andral and Hasse; the difference is rather one of names than 
of reality, for Rokitansky also admits that the walls of the air-cells are 
often implicated. He describes the inflammation as commencing be- 
tween the pulmonary lobules and the smaller groups of air-cells; the 
tissue, unless much carbonaceous matter be present, becoming of a pale 
red color, and being swollen by albuminous infiltration, while the air- 
cells are either pale or more or less compressed, in proportion to the 
swelling; or if they are involved in the inflammation, reddened, and 
sometimes finely granular. In the progress of time, the interstitial in- 
filtration becomes organized, coalesces with and obliterates the air-cells, 
and finally converts them into a similar tissue. In some cases this pro- 
cess may terminate in suppuration; in others it extends from lobule to 
lobule, at the apices of the lungs, and is frequently combined with cir- 
cumscribed pleurisy. 

Dr. Williams describes a chronic form of pneumonia, in which the 
hepatized portion, owing to the thickening of individual vesicles, assumes 
an oolitic aspect. He is of opinion that consumption may originate in 
this species of pneumonia without the pre-existence of any distinct 
tuberculous disease. It is not impossible that some of the fibroid con- 
tractions of the pulmonary tissue, which we meet with, particularly at 
the apices of the lungs, may be due to an arrest of chronic pneumonia 
as well as to previous pleuritic inflammation ; we occasionally meet with 
depressions in otherwise healthy lungs, which are unconnected with 
emphysema, and for which no other explanation can be offered than a 
foregone inflammatory condition of the interstitial tissues of an aplastic 
character, an opinion in which we are also borne out by the authority 
of Dr. Williams. 1 

1 Principles of Medicine, p. 313. London, 1843. 



CHAPTER XXX. 

ADVENTITIOUS PRODUCTS IN THE LUNGS. 

We now arrive at the consideration of a subject which, both in its 
scientific and in its practical bearings, is one of the utmost importance 
in connection with the morbid anatomy of the lungs more than with 
that of any other organ, the deposit of tubercular matter. In the sec- 
tion devoted to the general pathology, we have entered into the prevail- 
ing views entertained with regard to the nature of tubercle. The affinity 
between lymph and tubercle insisted upon by older writers, and recently 
more fully urged by Dr. Alison, Dr. 0. J. B. Williams, and, under the 
appellation of fibrinous erases by Rokitansky, must not be lost sight of, 
although it only states the one fact, that tubercle is a secretion of a 
morbid constituent of the blood, in different terms, without actually 
defining the character of the change. It leaves the relation between 
the salts of the circulating fluid and the albuminous constituents un- 
touched, nor does it determine whether any chemical agent which the 
exuded matter may meet with, in any way alters its nature, and thus 
converts what, in the first instance, may have been innocuous, into a 
deleterious agent. We are led to make these remarks by the interest- 
ing experiments lately published by Dr. Parkes, 1 on the "Precipitation 
of Albumen by Acids and Neutral Salts," which promise to throw much 
light on the ultimate constitution of tubercle, as well as upon many 
points connected with its origin and metamorphoses. Our limits will 
not allow us to detail the processes employed, but the conclusions arrived 
at are sufficiently important to justify their introduction at this place ; 
they are: 1. That the albumen in the serum of the blood is occasionally 
in a condition in which it is not precipitated by an acid and a neutral 
salt. 2. That if that albumen be exposed for some time to a strong 
alkaline solution it ceases to be precipitable by acids and salt. 3. The 
continued action of acetic acid on serum also annuls the action of acid 
and salt on albumen ; hence it is evident that the albumen, as it exists 
in the serum, is usually in that condition in which it is most easily pre- 
cipitated by acids and chloride of sodium; but that it very readily passes 
out of this condition under the continued influence of acids and alkalies, 
and is then, in all probability, incapable of reassuming it. Dr. Parkes 
also shows that, under certain circumstances, the albumen is found in a 
corpuscular condition, viz : in the form of round globules and cells of 
different sizes, sometimes inclosing each other, and forming conglome- 

1 Medical Times, 1850, July 27, and 1852, July 3. 
27 



418 ADVENTITIOUS PRODUCTS IN THE LUNGS. 

rates, and sometimes completely resembling the eye-globules of fat. 
The former observations indicate the nature of the bio-chemical changes, 
which obtain, when an aplastic deposit, such as tubercle, is effected, 
while the latter assist in explaining the fact that we meet with what is 
called fat or oil, in varying quantities in all tubercular deposits, and also 
aid in the intelligence of that morbid state of nutrition known under the 
term of fatty degeneration. 

The lungs are the organs which, above all others, are liable to tuber- 
cular deposit; a circumstance easily explained, if we admit that tubercle 
is derived directly from the blood, as the lungs are the chief organs of 
haematosis, and anything tending to check the purification and arrest 
the circulation of the current would also induce an elimination of the 
morbid element. Hence, too, the apices, from being inclosed in a less 
yielding case, mechanically favor the effusion more than the lower lobes. 
We are unable to reconcile with this fact the categorical statement of 
Rokitansky, that the main feature of the tuberculous crasis or diathesis 
consists in arteriality or a predominant arterial development of fibrin, 
since, if this were the case, we should certainly expect to find the tuber- 
culous deposit more frequently in the brain and kidneys than in the 
lungs, and more commonly in the interstitial tissue of the latter, as a 
secretion from the bronchial arteries, than in the respiratory vesicles. 
That the deposit is extravascular, is undoubted. Messrs. Gulliver and 
Addison have shown that it is effected on the surface of the air-cells, or 
under the basement-membrane, though our own observations lead us to 
believe that the primary deposit is invariably at the point of smallest 
resistance ; and hence, in the first instance, always into the free cavities. 
That, when these are filled, the morbid plasma may be deposited in the 
interstitial parenchyma, is certain ; Dr. Williams is even of opinion that 
tuberculous matter may form within the bloodvessels themselves, as he 
has repeatedly found something presenting all the external characters 
of yellow tubercle in the bloodvessels of tuberculous lungs. "In fact," 
he continues, "wherever fibrin may coagulate, there its degraded form, 
tubercle, may occur. It is but in accordance with the general rules of 
morbid formations, that the deposit of tubercle should undergo modifi- 
cations both in form and chemical constitution, according to the organ 
in which it appears and the habit of the individual ; hence, though its 
characters are sufficiently uniform to justify our treating it as a disease 
8ui generis, numerous variations present themselves, owing to the influ- 
ence to which we have alluded, which have given rise to conflicting state- 
ments. The microscope has more especially appeared to complicate, 
instead of solving the difficulties, owing to the presence of epithelium- 
corpuscles, nuclei, and proper corpuscles (as in the glands), in most of 
the parts where tubercular deposit occurs. The greater or less conges- 
tion, irritation, and inflammation coincident with tubercular deposit, has 
no less confused the doctrines relating to the subject; though, if we take 
the whole complex of pneumonia, and analyze the successive stages 
which we meet with, we shall find that the real obscurity is not so great 
as it at first sight appears. A material difficulty in the examination of 
diseased lungs is that, in all the early stages, the quantity of air contained 
in the tissue is so great as to constitute a considerable impediment to the 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 



419 



minute investigation; and, though the examination of dried or seasoned 
specimens may assist in elucidating some points of morbid anatomy, it 
is manifest that the most important questions will remain unsettled, unless 
we arrive at our conclusions from what we discover in the most recent 
examples. 

The primary deposit of tubercle takes place, in a semifluid form, into 
the vesicular cavity, which it distends so as to form a round point, of 
the size of a small pin's head, visible to the naked eye. It forms a 




Miliary tubercle, scattered throughout the pulmonary tissue, forming translucent, grayish, and circular 
points, of the size of pins' heads. 

translucent mass, which entirely blocks up the cavity, stopping abruptly 
at the entrance of the ultimate bronchule, like a bullet that exactly fits 
its mould. The fine basement-membrane of the vesicle is more or less 
obscured by the dark ring of exudation-corpuscles covering it, and which 

Fig. 189. 






I 



- 




Microscopic appearance of miliary tubercle. The drawing to the left shows the site of the deposit and its 
relation to the pulmonary tissues ; the effusion has taken place into the air-vesicle, which is distended into a 
globular ball. The drawing to the right exhibits a section of miliary tubercle without the bronchules, sur- 
rounded by congested vessels. 

we invariably find wherever there is any irritation accompanying the 
deposit, whether of a primary or a consecutive character. The ultimate 
divisions of the bronchi escape the power of unassisted vision, but, in a 
successful section, may be clearly seen with a power of twenty diameters. 



420 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 



This deposit scarcely encroaches upon the surrounding parenchyma; but 
when, instead of solitary vesicles being the seat of the exudation, whole 
clusters of breathing-cells are at once charged with tubercular matter, 
the microscopic appearances are rather those of a mould of grapes taken 
in blanc-mange, and we no longer detect the interstitial spaces, partly 
from the increased opacity of the deposit rendering it impossible to 
transmit light through a section of any thickness, partly from the com- 
pression exerted upon the interstitial tissue obliterating it. The oblite- 
ration of the pulmonary tissues progressively increases ; the rounded 
form of the vesicular structures is gradually destroyed ; by mutual 
pressure they assume an hexagonal or polygonal shape, a mere line indi- 
cating the points of separation ; the bronchules leading to this morbid 
mass are seen to be obliterated, dwindling down, near the tubercular 
aggregation, to a point, and ending, like a ligatured artery, in a mere 



Tig. 190. 



Fig. 191. 





Microscopic appearance of a mass of miliary 
tubercle, in close aggregation. 



Hexagonal appearance caused by the mutual 
pressure of the air-cells, filled with yellow tubercu- 
lar matter, with obliteration of the bronchulea 
leading to the lobules. Magnified 60 diameters. 



thread. The translucent character of the tubercle, by this time, is 
utterly lost ; it has assumed, partly owing to original constitution, but 
more, in our opinion, owing to secondary changes which have taken 
place in it, an opaque cheesy appearance, of a creamy or clayey color, 
resembling fresh Stilton or pale Cheshire, both in hue and consistency. 
If the tubercular matter be analyzed by the higher powers of the 
microscope in these various stages, we find that it presents corresponding 
differences in its ultimate elements. In the earliest and most recent 
form we see a fine molecular blastema of an almost homogeneous appear- 
ance, in which faintly, but definitely, the outline of lighter particles of 
an oval or circular shape, and from 0.0003" to 0.0002" in diameter, 
may be traced, themselves less granular than the stroma in which they 
are imbedded. The tubercle-corpuscle contains no nucleus, a point which, 
as M. Lebert has shown, is confirmed by the addition of acetic acid fail- 
ing to bring it out, and which serves to distinguish it from similar 
formations. The tubercular elements are not, as has been asserted, a 



ADVENTITIOUS PRODUCTS IK THE LUNGS. 421 

mere modification of epithelium; but though we frequently find epithelium 
mixed up with, and possibly, at times, closely resembling the more de- 
veloped forms seen in tubercle, they possess a character and evolution 
of their own. The denser the deposit, the more uniform the conversion 
of the blastema into definite oval, or somewhat angular corpuscles, with 
a definite cell-wall and granular contents. The corpuscle is not a mere 
lamina, but appears to have an ovoid shape. A new process of disinte- 
gration now appears to ensue, and we see the elimination of a large 
number of highly refracting particles, hitherto considered as fat or oil, 
but possibly, according to the experiments of Dr. Parkes above alluded 
to, peculiar modifications of albumen. When the tubercular deposit has 
arrived at this stage it appears that an arrest of the morbid process may 
take place, it may become obsolete, and undergo changes that enable 
the system to bear its presence without serious inconvenience, or the 
morbid process advances with more or less activity, inducing a softening 
of the deposit, and a destruction of the pulmonary tissue, all of which 
we shall have occasion to investigate further on. 

We now turn to consider the morbid phenomena and changes in the 
pulmonary tissues associated with the deposit of tubercle. These are 
of a more or less active character, according to the exciting and predis- 
posing causes operating in the individual case, and according to the 
general habit of the patient. It has, therefore, become customary to 
form two groups of pulmonic tubercular diseases, the acute and the 
chronic. Other authors have preferred dividing the subject, according 
to the characters presented by the tubercular deposit, into the gray or 
yellow varieties, or, as Rokitansky more particularly has done, according 
to the place of deposition, into the interstitial and infiltrated form ; the 
former term being applied to tubercular matter exuded into the inter- 
vesicular textures, the latter to its occurrence within the cavity of the 
vesicles. We have already seen that the density of tubercle varies with 
the period of its deposit, and with the amount of pressure it may be 
accidentally exposed to. No important characteristic seems to depend 
either upon its color, except that the most decidedly gray and translucent 
form is the more recent, and most commonly connected with a more 
actively inflammatory condition of the parts; the same influences which 
induce the change of form and consistency undoubtedly modify, together 
with the molecular alterations that coexist, the color of the deposit. 
Still, the deposit may, from the first, present an opaque yellowish ap- 
pearance, and, as Carswell observes, the gray, semi-transparent sub- 
stance does not necessarily precede the formation of the pale yellow or 
opaque tuberculous matter. After the tubercular matter has become 
firm, it may, at some future period, be converted into a pulpy grumous 
fluid, presenting various colors of a greenish, red, brownish, or other 
hue, dependent upon the admixture of serum, blood, or pus, which pervade 
the substance of the tubercular matter, loosening and detaching it. From 
this it follows that there must be some error in the commonly received 
doctrine, that the softening always commenced in the centre of the 
deposit. We commonly find a depression in the middle of an accumu- 
lation of tubercular matter. This has been attributed by Laennec to 
softening. Carswell's explanation is as follows : " When tuberculous 



422 



ADVENTITIOUS PKODUCTS IN THE LUNGS. 



matter is found in the lungs it is generally contained in the air-cells and 
bronchi. If, therefore, this morbid product is confined to the surface 
of either, or has accumulated to such a degree as to leave only a limited 
central portion of their cavities unoccupied, it is obvious that when they 
are divided transversely the following appearances will be observed. 
1. A bronchial tube will resemble a tubercle having a central depression, 
or soft central point, because of the centre of the tube not being, nor 
ever having been, occupied by tuberculous matter, and because of its 
containing a small quantity of mucus or other secreted fluids. 2. The 
air-cells will exhibit a number of similar appearances or rings of tuber- 
cular matter, grouped together, and containing in their centre a quantity 
of similar fluids. When the bronchi or air-cells are completely filled, 
the tuberculous matter presents no such appearances as I have described, 
and hence the reason why tubercle, in such circumstances, has been said 
to be still in a state of crudity, or that condition which precedes the 
softening process. Softening begins most frequently at the circumfer- 
ence of the tuberculous matter, or where its presence as a foreign body 
is most felt by the surrounding tissues. Hence, the reason why softening 
is frequently seen making its appearance in several points of an agglo- 
merated mass of this substance, which has included within it portions of 
the tissues in which it was formed. This is frequently observed in the 
lungs, and cellular tissue in other parts; whereas, in the brain, the sub- 
stance of which has, from the commencement, been separated and pushed 
outwards by the tuberculous matter, the softening process begins, and 
is always most marked on the circumference of this morbid product." 

As we have assumed that there is essentially but one form of tubercle 
possessed of characters sufficiently definite to justify the classing under 
one head varieties which owe their differences to accidental or trifling 



Fig. 192. 



Fig. 193. 





Microscopic appearance of minute vessels, sur- 
rounding air-vesicles in tubercular pneumonia, 
and miliary tubercle. 



A section of an air-vesicle filled with yellow tubercle, 
and surrounded by exudation-corpuscles. 



circumstances, and as we believe that the diathesis of the blood and the 
general constitution of the individual are essentially the same, in which 
the deposit is effected, so also are the symptoms and local changes 



. ADVENTITIOUS PRODUCTS IN THE LUNGS. 423 

accompanying the elimination of tubercle more or less the same in the 
different cases. They are essentially those of a low type of inflam- 
mation. The primary deposit of tubercle is always accompanied by an 
increased afflux of blood to the part ; hence the great danger in scrofu- 
lous subjects of the slightest catarrhal inflammation, because the diathesis 
being present, nothing is required to induce the deposit but a congested 
state of the parts generally liable to it. The further evidence of an 
inflammatory process is given in the constant occurrence of exudation- 
corpuscles in the immediate vicinity of the air-cell into which the effu- 
sion is taking place, or has recently been effected. These corpuscles, 
whether in the form of cells with a proper wall, or of mere aggregation- 
molecules, are seen entirely coating the air-vesicle if we obtain a view 
a posteriori ; or, if we succeed in making a transverse section, a dark ring 
formed by these corpuscles, and probably external to the basement- 
membrane, between the vessels and vesicular coat, is seen bounding the 
tubercular matter. This point the more deserves attention, because in 
certain experiments made by Gluge to disprove the views entertained 
by Dr. Addison, that the morbid state of the lungs accompanying acute 
miliary tubercle is of an inflammatory character, stress has been laid 
upon these corpuscles being distinct from tubercular matter, and that 
the error had arisen from their being in the previous experiments mis- 
taken for the cacoplastic exudation itself. Their characters are cer- 
tainly well defined, and it is this point that, in our opinion, confirms 
the views of the inflammatory nature of the process, which, not only in 
miliary, but in every form of tubercular deposit, accompanies its elimi- 
nation. In the words of Dr. Graves, the most important thing for the 
student to impress on his mind, with regard to all cases of phthisis, is, 
that the pectoral symptoms, of whatsoever nature they may be, are 
caused by scrofulous inflammation. The haemoptysis which is found to 
precede or accompany two-thirds of all cases of pulmonary consump- 
tion, and is so constantly connected with tubercle, that Louis has laid 
it down as denoting with infinite probability the actual presence of 
some tubercles in the lungs, at once furnishes a proof of the manifest 
congestion accompanying the lesion, and of the peculiar aplastic condi- 
tion of the blood, by which, under comparatively slight exciting causes, 
it is forced through the coats of the vessels. This haemoptysis also con- 
firms the view we have advocated with regard to the intra-vesicular 
character of tubercular effusion ; we never find any symptoms of apo- 
plectic hemorrhage, or hemorrhage within the pulmonary parenchyma 
accompanying tubercular disease, but it is invariably an exhalation on 
the free surface of the respiratory membrane. Now it is fair to con- 
clude that if the tubercular blastema were effused interstitially in the 
first instance, we should here also, in a proportional number of cases, 
find the results of hemorrhagic effusion, which is not the case. 

With reference to the mode in which tubercle is distributed through 
the lungs, we find that it presents three varieties, which are generally 
tolerably defined in the lungs of one individual, though occasionally the 
several forms of deposit occur together. Hasse describes them in the 
following terms: "First, they are found single, isolated, and more or 
less uniformly disseminated miliary tubercles ; secondly, they are found 



42-i ADVENTITIOUS PKODUCTS IN THE LUNGS. 

in scattered groups, assuming various forms, the tubercles being now 
loosely collected together, now closely connected either in a regular 
mulberry shape, or in clusters of indefinite form, aggregate tubercles; 
thirdly and lastly, they are found densely crowded throughout a por- 
tion if not the whole of a lobe, so as to constitute seemingly but one 
coherent mass, tuberculous infiltration." We also coincide with the 
observations which follow the preceding extract: " Their mode of dis- 
tribution is naturally influenced by their mode of development. Where 
they form rapidly they are the more equally dispersed, where slowly 
they become in the same measure subject to the law which causes them 
to accumulate in the summit of the lung, and from thence downwards 
gradually to decrease in compactness, with a proportionate tendency to 
run into groups. The aspect of the individual tubercles is also modified 
by the manner of their distribution, the gray variety in particular be- 
coming whiter and losing its transparency, when densely congregated." 

A species of antithesis exists in the lungs between the tendency to 
tubercular deposit in their apices and the liability of the lower lobes to 
idiopathic inflammation. This may be accounted for by the encourage- 
ment to deposition from the blood offered in the apices of the lungs, by 
the lesser expansibility of these parts. The movement of the clavicle 
and two upper ribs is very small compared with that of the lower ribs, 
and the intercostal muscles are more rigid here than below, circum- 
stances that are enhanced by a sluggish habit, while they favor any 
accidental impediment to the aeration of the blood. This, in its turn, 
diminishes the rapidity of the current as well as its quality; hence the 
morbid deposition ensues, and, as the cavities of the air-vesicles are the 
points of least resistance, the effusion is effected into them. We have 
already mentioned that the more rapid the course of phthisis, the more 
generally we find the deposit diffused through the lung. In a case of 
acute miliary tubercle, from which one of our illustrations is taken, the 
bases and the apices of both lungs were uniformly affected; both organs 
being studded throughout with the deposit, which had probably taken 
place but a few days previous to death, in a subject debilitated by rheu- 
matic affection of the heart and central softening of the brain. Both 
lungs, according to the law of symmetry, present a proclivity to tuber- 
cular disease; Laennec considered that a greater tendency existed on 
the left than on the right side, owing to his having met with five in- 
stances in which it was limited to the left lung, while only two occurred 
to him in which the right alone was the seat of disease. Other ob- 
servers have failed to confirm Laennec's observation, and have asserted 
either that the right lung was more frequently affected, or that no dif- 
ference was traceable. If a difference exists in the early stages of the 
disease; and it is probable that, in its progress, the balance is restored; 
our own experience decidedly tends to show a predominance on the 
right side, in the incipient period. 

The questions which next suggest themselves for our consideration 
are the ulterior processes which the tubercular matter and the pulmo- 
nary parenchyma undergo after the deposit has been effected. They 
may be of an opposite character; either exhibiting a progressive deve- 
lopment, a tendency to destruction of the part and dissolution of life; 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 420 

or manifesting a retrograde movement, with evidence of the product of 
the disease becoming obsolete, and the morbid germ being extinguished. 
After the first deposit of tubercle is completed, the morbid diathesis 
may, as it were, have exhausted itself, and the process enters into a 
state of abeyance, all active symptoms being arrested; or the inflam- 
matory action is perpetuated and the course is continuous to the fatal 
termination. In the former case, every recurrence of bronchitic or 
pneumonic inflammation finds a nidus of tubercle around which fresh 
matter is deposited, or which becomes an additional source of irritation. 
In both cases a process of fusion takes place, serum and pus are se- 
creted from the parts in which the morbid deposit has been effected, the 
intervesicular septa are more and more absorbed and broken down, the 
softened matter finds its way into the larger bronchi and is expectorated, 
a mixture of pus, mucus, melanotic, oily, and granular matter, interspersed 

Fig. 194. 




The apex of a lung affected with tubercular pneumonia ; the limitation of the disease was defined by a 
sharp line bounding the inflamed tissue, which surrounded the tubercular deposit. 

with epithelium and the elastic fibres of the lungs, and the result is a 
cavity in the pulmonary tissue. The walls of this cavity may be more 
or less rugged, and be more or less lined with tubercular matter, or 
present no traces of it, according to the date of its formation ; these 
tubercular cavities were formerly often mistaken for genuine abscesses 
— we find them in all numbers ; there may be but one, or so many as to 
give the entire lung a riddled or honeycomb appearance when cut into; 
they vary equally in size, from a pea to a man's fist and more. The 
communication between the abscess and the bronchus passing out of it, 
resembles a fistulous opening, the peculiar relation of which to respira- 
tion causes many of the phenomena of auscultation. It is rare, as 
Laennec observes, to find a single cavity; the excavation is commonly 
surrounded by crude and miliary tubercles which gradually soften, are 
then discharged into the main cavity, giving rise to the anfractuosities 
which we commonly observe. The excavations are often traversed by 
bands of pulmonary tissue infiltrated with tubercular matter, and com- 
pared by Laennec to the columns carneae of the heart. He also sug- 
gests that they were mistaken by Bayle for vessels passing across the 
cavities, for vessels are scarcely ever seen in this position. The pro- 
gress of the tubercular deposits causes the obliteration of the vascular 
channels as of the other parts of the normal tissue, and we only find 
the vessels of a larger caliber in the vicinity of the cavities. The 



426 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 



bronchules, and successively the larger air-tubes, are subjected to the 
same destructive agency, until the power of resistance caused by the 



Fig. 195. 




A lung, exhibiting extensive tubercular disorganization throughout its upper lobe, which is almost con- 
verted into one rugged cavity. The pleura is very much thickened ; intimate adhesion has taken place be- 
tween the upper and lower lobe, and the tubercular deposit is seen encroaching upon the latter. 

stronger walls of the bronchi of the first and second order is too great 
to be overcome by the morbid process. 

Instead of a mere uneven rugged surface, as if the lung had been 
mouse-eaten, the walls of the abscess often present a uniform velvety 
appearance, and are invested by a false membrane, which may assume 
a considerable thickness of one-third or half a line. At the earlier 



Fig. 196. 




The apex of a lung containing numerous cavities, with tubercular deposit intervening. The large cavity, and 
several of the smaller ones, are lined with an adventitious membrane. 

periods of disease, the membrane is of slight consistence and easily 
separable. The membrane is described by Hasse as being formed out 
of the bepatized crust that encircles the enlarging cavities, and which, 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 4'27 

instead of becoming softened and liquefied through purulent formation, 
merely becomes saturated with coagulable substances more akin to the 
organism; "but," he continues, "no sooner is the tubercular diathesis 
revived and aggravated by a catarrhal or inflammatory attack, than the 
protecting false membrane liquefies, and purulent secretion, mingled 
with tubercle, again sets in. The cavity itself, which under the above 
circumstances seemed to shrivel and contract, gains size, new vomicae 
form, the lung becomes more and more deeply involved, and the mis- 
chief terminates only in death." The tissue beyond the lining mem- 
brane may be in a healthy condition, or present tubercular deposit in 
various degrees, but generally containing much melanotic carbonaceous 
matter. In the majority of instances both lungs are found to present 
excavations. Louis states that in one-sixth only of his total cases of 
phthisis, they were limited to one or the other lung, and when present 
on both sides were of different size ; in somewhat less than one-tenth of 
his cases, both lungs were the seat of enormous excavations, equally 
large on both sides, and in another tenth, where the cavities presented 
but small or moderate dimension, these dimensions were the same in 
both organs. Large cavities (of the size of a goose's egg or a clenched 
fist) Louis found to occur in about one-half of the cases, and with equal 
frequency in each lung ; in the remainder of his subjects he found cavi- 
ties of the size of an ordinary-sized apple or walnut. 

The complications of disease occurring in the course of tubercular 
phthisis and at different periods, are inflammations of the mucous mem- 
branes of the air-passages of the pulmonary parenchyma and of the 
pleura. Of the appearances presented by the first, and of the relative 
frequency of occurrence in them of ulcerations in consumption, we have 
already spoken. There can be no doubt that the acrid character of the 
expectorated matters very much favors the ulcerative process. The 
frequency with which slight attacks of pneumonia supervene in the 
course of phthisis, is not surprising, if we look upon it merely as an 
exacerbation of the process actually constituting the disease — it is rather 
in each case the cause of an extension of the morbid deposit, than the 
result of the previous elimination of tubercle. The pleurisy accompany- 
ing tubercle, may supervene at various periods, and by the adhesions it 
causes and the consequent increased immobility of the lung, it necessa- 
rily much favors the development of the tubercular process. That the 
tubercular deposit has a tendency to excite pleurisy, is evident from the 
frequency with which the latter occurs at the apices of the lungs, often 
forming a complete cartilaginoid cap from which it is difficult or impos- 
sible to detach the lung entire. When tubercular excavations approach 
close to the pleural surface, and are not preceded by thickening of the 
pleura, as generally occurs, a perforation may take place, inducing effusion 
of air and liquid into the cavity and secondary inflammation ; we then 
have to deal with hydro-pneumothorax, upon which a rapidly fatal issue 
is almost certain to follow. Mere cellular adhesions, according to Roki- 
tansky, cannot prevent this termination ; they are, in part, mechanically 
loosened by the effusion from the cavern, and being involved in the pleu- 
ritic process, they are in part likewise destroyed in the exudation. 
Rokitansky describes three forms in which the communication between 



428 ADVENTITIOUS PRODUCTS IN THE LUNGS. 

the tuberculous cavity and the sac of the pleura may be established ; the 
pulmonary pleura may be detached from the affected surface by the 
mere force of the air rushing in so as to form a bulla, which after- 
wards bursts ; it may be converted into a whitish eschar which tears or 
becomes detached unbroken, or the pleura, together with the infiltrated 
parenchyma surrounding the cavern, may become gangrenous and be 
converted into a purilage. The complication of pulmonary tubercle 
with tubercular deposits in other organs is of very common occurrence; 
Louis 1 found tuberculous ulceration in the intestines in five-sixths of the 
cases he examined, the lymphatic glands were affected in the following 
order of frequency, the bronchial most, next the mesenteric, the axillary, 
mesocolic, lumbar, and cervical ; the spleen and kidneys exhibited tuber- 
culous deposit in about one-sixth of the cases ; several times the prostate 
was found more or less transformed into tuberculous matter, and tuber- 
cular deposit was also met with in the cerebral arachnoid, though the 
frequency is not stated. The prevailing condition of the liver in pul- 
monary phthisis is one of fatty degeneration. Louis found it fatty in 
one-third of his cases. With regard to the coexistence of pulmonary 
tubercle, with tubercular deposit in other organs, the general law has 
been established, that wherever, after the age of fifteen, tubercles pre- 
sent themselves in any organ of the body, we are certain also to meet 
with them in the lungs. 

When the tubercular deposit in the lungs does not advance and 
undergo the progressive changes which we have described, a process of 
obsolescence occurs which appears to consist in certain chemical changes 
in the tubercular matter, accompanied by an extinction of the peculiar 
crasis which had given rise to its elimination, and followed by certain 
secondary alterations in the surrounding tissues by which they are 
adapted to the requirements of the case. These we find to exhibit two 
distinct forms, which probably depend upon a difference not yet pro- 
perly appreciated or well defined, in the diathesis primarily giving rise 
to the deposit. They are characterized by a fibrinous or a calcareous 
metamorphosis. In the former case we find the tubercle assuming a 
more dense and leathery character, qf a semi-cartilaginous consistency, 
drying or shrivelling up as it w T ere, accompanied by a contraction of the 
superimposed tissue. If we examine the yellowish deposit under the 
microscope, we find mixed up with the ordinary forms of tubercle a dis- 
tinct fibrinous formation exhibiting a linear, striated appearance. In 
the latter, a conversion of the tubercular matter seems to be effected 
into a chalky substance, at first moist and soft, gradually, owing to 
absorption of the fluid constituents, becoming harder and drier, and, at 
the same time, shrinking from its previous dimensions ; thus, at times, 
we find, to use Hasse's words, "that a considerable portion of the lung, 
as may be inferred from the size of the bronchial tubes leading thither, 
becomes reduced to a hard shell, holding in its centre a chalky tubercle 
no bigger than a pea." The chemical characters of these formations 
have already been alluded to ; but it may be well to remind the reader 
that, although termed chalk, they do not consist of carbonate of lime, 

1 Researches on Phthisis, Syd. Soc. Ed. p. 150. 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 429 

or of the elements of gouty chalkstones, urates of soda, but that they 
are mainly composed of chloride of sodium and sulphate of soda, as de- 
monstrated by the researches of M. Boudet. 1 Lebert has also repeatedly 
observed cholesterin in chalky tubercles. The black pigment, which 
is at times met with to a considerable amount in tuberculized lungs, and 
still more in the bronchial glands, does not present any different features 
from that commonly found in the pulmonary parenchyma. It appears 
to consist of pure carbon, and may present a mere amorphous granular 
form, imbedded in and scattered irregularly through the tissue, or it is 
found inclosed in an epithelial cell. That it bears some relation to the 
defective oxygenation of the blood, is manifest from the normal tendency 
to the deposits being greater in proportion to the advance of life ; and 
it has appeared to us to accumulate very rapidly in some cases of chronic 
inflammation. The presence of this black matter in the expectoration 
of phthisical patients in part gives rise to the grayish or dirty tinge we 
frequently observe. 

Obsolete tubercle is surrounded by a dense capsule resulting from 
inflammatory induration. It is commonly found at the apices of the 
lungs, and may be easily felt on handling the part, and, if near the sur- 
face, their effect is rendered visible by a drawing in and puckering of 
the pleural surface. 

The metamorphosis of tubercle into fibrinous or cretified masses must 
be regarded as evidence of a curative tendency. Whether we are 
justified in assuming, as it appears Carswell 2 does, that an entire ab 
sorption of tubercular matter may take place without a metamorphosis 
of this kind, or without the formation of a cavity, is a question which 

Fig. 197. 




Cicatrix at the apes of a lung, resulting from the previous arrest of tubercular disease. 

we are not prepared to answer positively, though there is no certain 
proof to the contrary. That the healing process is not limited to the 
first stages of the disease, but is also seen after the formation of cavi- 
ties, is established by the unanimous testimony of the best observers. 
Andral remarks that traces of cicatrization are found in individuals 
who, at one period of their life, have been subject to a severe affec- 
tion of the respiratory organs, which was regarded as phthisis, or in 
such as have been cured of a previous pulmonary attack, but have suc- 

1 Rechercb.es sur la Guerison Naturelle ou Spontane'e de la Phthisie Pulmonaire. 
Paris, 1843. 

2 Elementary Forms of Disease, Art. Tubercle. 



430 



ADVENTITIOUS PRODUCTS IN THE LUNGS. 



cunibed to a subsequent one of the same character; or, lastly, in persons 
who from the first day of their cough have continuously grown worse, 
in whom, therefore, after the cicatrization of one cavity new ones had 
formed. The cavities may disappear altogether, leaving a dense white 
fibrous tissue, ramifying irregularly in the surrounding tissue ; or the ob- 
literation is incomplete, the cavity remains partially open, and the cha- 
racter of the lining membrane undergoes a change assimilating it to a 
serous membrane, or, which is more commonly the case, converting it 
into a vascular villous covering, resembling a mucous membrane. Roki- 
tansky states that, in the latter case, aneurismal dilatation, or a gela- 
tinous degeneration of the vessels subjacent to the membrane, is liable 
to give rise to hemorrhage into the cavity, which either proves fatal, or 
else, by coagulating and plugging up the vessel, becomes a further means 
of obliteration and ultimate cure. 

Before quitting the subject of pulmonary tubercle, we have to allude 
to certain differences which exist between the manifestation of the dis- 
ease in early life and later years. In the former instance, the lungs 
are much less liable to become the seat of the deposit than they are in 
the latter ; it is more commonly simultaneously deposited in a greater 
number of organs ; and while, according to the extensive researches of 
Messrs. Rilliet and Barthez, which are confirmed by those of Dr. "West, 
the yellow form of tubercle largely predominates, there is a remarkable 
immunity from tubercular cavities. The cavities that do occur are much 
smaller in proportion, and, though occasionally very numerous, do not 
give rise to the same amount of destruction of the pulmonary tissue 
that we see in the adult. The differences alluded to may be accounted 
for, partly by the greater share the nutritive organs take in all the 
functions of early life, and partly by the proclivity existing in the lungs 
to lobular inflammation. The latter circumstance renders it probable 
that a minute examination of tubercle in the infant, would exhibit a 
greater production of pus coincidently with the elimination of tuber- 
cular matter, than is found in the adult. We extract the following 
table from Dr. West's classical work on the diseases of childhood, as 
the best illustration that can be offered of the relation borne by tuber- 
cle to the different organs of the body in early and advanced life. 

Of 100 instances in which tubercle was deposited in some of the 
viscera, it was present in 



The lungs 

Bronchial glands 

Mesenteric do. 

Small intestines 

Spleen 

Pleura 

Peritoneum 

Liver 

Large intestines 

Membranes of the brain 

Kidneys 

Brain 

Stomach . 

Heart and pericardium 



Children from 

1 to 15 years. 

According to 

clilliet & Barthez. 


Adults from 20 years and 
upwards. 
According to According to 
Louis. Lombard. 


84 


100 


100 


79 


28 


9 


46 


33 


19 


42 


33 





40 


13 


6 


34 


2 


1 


27 








22 





1 


10 


10 





16 





2 


15 


2 


1 


]1 


0.8 


2 


6 








3 









CANCER 



431 



The table, as Dr. West remarks, shows not only that the liability of 
certain organs to become the seat of tubercle, is different in childhood 
from what it is in the adult ; but, also, that tubercle is simultaneously 
deposited in a greater number of organs in the young than in the old. 



CANCER, 



Malignant disease of the lungs is not a common disease. Mr. Adams's 
research has, however, shown that it occurs more frequently, both as a 
primary and as a secondary affection, than was supposed to be the case 
by Bayle, who, in 900 subjects examined, only once met with cancerous 
growths in these organs. Both Laennec and Bayle only found the me- 
dullary variety ; other forms have since been met with, but the ence- 
phaloid is that which vastly preponderates. Hasse has seen an instance 
of colloid cancer ; in the Reports of the Pathological Society of Lon- 
don for 1849-50, a case of primary fungus nematodes of the lung is 

Fig. 198. 




Infiltrated cancer of the lung, with its microscopic elements. The lighter part is that containing the de- 
posit ; it was of a brownish-red tinge, and of greater density and hardness than the unaffected parts. It 
occurred in the right lung of a young woman, aged 34, whose right bronchus was surrounded with a mass of 
medullary cancer ; the right kidney also contained a large growth of the same bind, and the 11th dorsal 
vertebra, especially its right side, was extensively destroyed by the same disease. 

detailed by Mr. Adams. The only fact by which it appears that we 
may determine the primary or secondary character of the deposit, is 
the circumstance of the lungs either being the sole, or, at any rate, the 



432 CANCER. 

chief seat of the disease. It is stated by high authorities, that the 
former always assumes the infiltrated character, while the latter appears 
exclusively in nodules or isolated tumors scattered through the lungs. 
This distinction cannot, however, be rigidly maintained. The pulmo- 
nary texture entirely vanishes in the malignant growth, while the sur- 
rounding tissue is compressed and its functions interfered with. The 
neighboring lymphatic glands are invariably involved in the degenera- 
tive process. With regard to the parts of the body from which cancer 
spreads to the lungs, Hasse remarks " that the bones and testicles ap- 
pear to furnish the most frequent starting-point ; and numerous exam- 
ples tend to show that surgical operations for the removal of cancer in 
those parts, are very speedily followed by its transition to internal 
organs. Many instances are adduced in w T hich the skin and the mam- 
mary glands, the uterus, the liver, the membranes of the brain, were 
first assailed. I have seen a very remarkable instance consecutive to 
primary cancer of the submaxillary gland. On the other hand, cancer, 
in organs whose veins are tributary to the portal system, does not ap- 
pear to spread to the lungs, although it is known to lead very often to 
corresponding disease of the liver." To this we would add that malig- 
nant disease, occurring in the mediastina, as it frequently does, does 
not appear to possess a great tendency to affect the lungs. We often 
see large masses of cancerous growth occupying these parts, and, per- 
haps, causing death, as well by suffocation as by exhaustion, without a 
trace of malignant disease in the lungs, although there is proximity of 
tissues as well as an intimate relation by the bloodvessels. The only 
case of the pancreatic variety, to use Abernethy's apt designation, that 
has lately fallen under our observation, entirely filled the upper part : p 
the anterior mediastinum, and infiltrating the pectoral muscles of the 
right side without affecting the lungs, otherwise than by pressure. A 
good instance of reticular carcinoma of the posterior mediastinum was 
exhibited by Dr. Jenner, at the Pathological Society of London, 1 which, 
however, slightly encroached upon the root of the lung ; we had an 
opportunity of examining it, and could, therefore, confirm the fact of 
the reticular character. Neither of these varieties has been seen to 
occupy the pulmonary texture. Whether the peculiar functions of the 
lung influence the nature of the deposit, or whether this depends upon 
some other cause, there is no evidence to show. 

A law universally adopted, and one that appears perfectly consistent 
with the inherent tendency to endogenous multiplication in cancer, and 
the absence of this character in tubercle, is, that the cancer does not 
coexist with tubercle. We do not wish to assert that there are no ex- 
ceptions from the rule; but they are so rare, and in those instances on 
record the diagnosis generally admits a reasonable doubt, so that the 
law is in no way invalidated. 

In connection with cancer, we have to allude again to an excessive 
deposit of carbonaceous matter in the lungs ; when this is the case, we 
have to deal with what Carswell has termed melanoma. The excessive 
secretion from the blood of black pigment accompanies the normal pro- 

1 See Reports, 1851-52, p. 253. 



CYSTS. 433 

cess of involution, tubercular disease and cancer ; and, as we have 
already had occasion to observe, appears to be mainly due to the inter- 
ference with the oxygenation of the blood. Carswell himself admits 
the complication of true melanosis with fibrous, carcinomatous, and 
erectile tissues, and since it does not in itself offer any characteristic 
features which would serve to establish its pathological identity as an 
independent formation, we are justified in regarding it rather as an 
accidental addition than as an essential constituent of a physiological or 
pathological tissue. 

CYSTS. 

The formation of cysts in the lungs is of rare occurrence and per- 
fectly latent, so that they are not discovered until after death, unless 
they excite irritation ; they may then find their way into the bronchi 
and be expectorated. They occupy the lower lobes of the organs ; they 
consist themselves of a double membrane of a clear pellucid appearance, 
which, under the microscope, present an homogeneous, delicately lami- 
nated structure. The laminae form parallel lines, so as to resemble the 
pages of an open book. The pulmonary tissue adjoining the cyst is 
covered by a dense membrane, so that, although entirely surrounded by 
the pulmonary parenchyma, there is not in reality any real intimate re- 
lation with it. They generally contain a limpid fluid, and present an 
endogenous development of hydatids of the same character as the parent 
cyst. They vary in size, but an instance which occurred to us of an 
acephalocyst, sufficiently capacious to contain a hen's egg, must be 
looked upon as unusually large. It neither contained secondary hyda- 
tids nor echinococci. A unique case of cysts in the lungs, filled with 
air, is quoted by Hasse. 1 

1 Pathological Anatomy, Syd. Soc. Ed. p. 337. 



28 



CHAPTER XXXI. 

PLEURITIS. 

The serous sac inclosing the lungs and serving to facilitate the move- 
ments of respiration, is more prone to morbid affections than any other 
serous membrane ; of these, inflammation is the most frequent, and one 
that arrests the physician's attention very commonly both in the pa- 
tient and in the dead subject. Some of the products of inflammation 
were formerly set down to physiological causes, owing to their being 
frequently met with in individuals whose histories did not give evidence 
of pleuritic inflammation having occurred in the course of their life. 
But the inference is not just, because even in severe pleurisies the 
symptoms are not necessarily of a character to attract the patient's at- 
tention, and most persons are familiar with the occurrence of occasional 
pains, of a not very enduring character, which may be accompanied by 
some effusion, though not of sufficient intensity to interfere with the 
function of respiration. The great frequency of the concurrent inflam- 
mation of the pulmonary tissue and its investing membrane, has given 
rise to a frequent misapplication of the term, and to a variety of theories 
in reference to the cause of pleurisy. So distinguished an author as 
Portal attempted to prove that pneumonia was not essentially different 
from pleuritis; but since the more careful prosecution of morbid anatomy, 
and the clearer distinction of symptoms during life which we owe to 
auscultation, no doubt exists that the two, though often associated, differ 
in their symptomatology as they do in their etiological and pathological 
relations. 

The first stage of inflammation of the pleura is manifested by the 
appearances of greater or less congestion, causing a multitude of ves- 
sels, not visible in the perfectly healthy pleura to the naked eye, to be- 
come filled with blood; a marked distinction may sometimes be observed 
between the venous and arterial channels, as exhibited in the different 
colors of the two systems. The vessels form an irregular network, and 
the more intense the inflammatory condition, the more uniform the red- 
ness becomes. At times, we find the character of the congestion to be 
more punctiform, and to resemble, as Laennec has it, an attempt made 
to dot over the pleural surface with a paint-brush, with small spots of 
blood of an irregular shape, and closely approaching one another; it is 
probable that in many cases this appearance is due, not to the peculi- 
arity of the disease, but to a partial emptying of some vessels as a post- 
mortem effect. The membrane, at the parts most affected, soon loses 
its natural transparency and gloss, in consequence of a secretion from 



PLEURITIS. 



435 



the overcharged vessels investing its surface with a coating of lymph 
or fibrin, a straw-colored semi-gelatinous effusion which may be easily 

Fig. 200. 




Fig. 201. 



Straw-colored lymph, coating the lower lobe of an inflamed lung, in recent pleurisy, before there was a 
trace of adhesion to the costal pleura. The outline represents one of two coils of new vessels, seen under 
the microscope in the fringe of lymph at the lower end. 

stripped off from the serous membrane. The microscopic appearances 
of this fibrin are delicate linear fibrillge, of a generally parallel direc- 
tion, enveloping and entangling the gran- 
ular and corpuscular forms observed in 
fibrinous exudation. We very rarely meet 
with cases of what Andral has termed dry 
pleurisy, as the effusion is a rapid sequel 
of the first stages of inflammation; but 
we frequently have an opportunity of ob- 
serving a limited plastic exudation at one 
point, while the greater part of the re- 
maining pleura or its fellow may exhibit 
the first stage of the disease. In the re- 
cent cases of sthenic inflammation, the 
effusion presents the appearance of a thin 
layer of thick cream, which, at the most 
dependent parts, seems to be dropping 
from the organ. The older the effusion, 
the more it assumes a membranous • cha- 
racter, the friction and compression to which 
it is subject giving to it an irregularly 
honeycomb or cellular appearance, or 
causing it early to put on a filamentous 
or mossy form. The plasticity of the 
effusion is in a ratio with the plastic cha- 
racter of the blood; hence, it does not always present the characters just 
described, but varies much in cohesion, in color, and quantity, accord- 
ing to the constitution of the individual attacked, and according to the 




Portion of the lower lobe of the left lung 
of a patient, compressed by turbid serum, 
occupying the pleural cavity. A thick 
layer of lymph covered the hepatized por- 
tion of lung ; it was perfectly smooth from 
the contact with the liquid, and there was 
a free scalloped margin at some parts, of 
an inch in breadth. The exudation-mat- 
ter consisted of filamentous matter, en- 
tangling corpuscular fibrin. 



436 PLEURITIS. 

exciting cause; thus we may, even in the same subject, meet with differ- 
ent products of inflammation at different parts of the same lung. The 
exudation may be of a more serous or of a purulent character, in which 
case the sac will contain more or less of these fluids in which we find 
portions of lymph detached from the pulmonary surface floating about, 
while their peculiar color, from an admixture of more or less blood, 
may present a proportionately reddish tinge. The more asthenic the 
type of the inflammation, the more the effusion departs from the cha- 
racter of a plastic exudation, the more inorganizable it becomes. While 
the discharge upon the inflamed surface of organizable material is emi- 
nently the result of acute pleuritis, the effusion of aplastic or cacoplastic 
matter is connected with the chronic forms. 

At one time, pus and puriform secretions from serous surfaces were 
considered organizable ; a doctrine of which Villerme' and Dupuytren 
were the chief exponents, but which is now entirely exploded, the 
general view being in the main that advocated by Dr. Hodgkin: 1 that 
these matters are always more or less excrementitious, and that, where 
an outlet from the body is not afforded, they invariably retard the cure 
by interfering with the progress of organization in those substances 
which are formed in conjunction with them, and are susceptible of this 
change. 

When the progress of sthenic pleuritis is uninterrupted, the change 
that next ensues after the effusion of coagulable lymph on the surface 
of the membrane, is the formation in the former of new vessels, and 
such further alterations in the exudation itself as to induce an assimi- 
lation to surrounding textures, and a re- 
storation to a state of comparative, if not 
absolute, health. The adventitious mem- 
branes that thus become permanently 
formed are of greater or less extent, and 
may be limited to the one pleural surface, 
or connect the pulmonary and costal 
pleura ; thus giving rise to further im- 
portant changes of structure, which may 
seriously involve the entire thorax, and 
consecutively even affect the spinal co- 
lumn. The adhesions are of an opaque, 
whitish hue, and become more firm the 
older they are. The great frequency 

The lymph of pleuritis, with new vessels w J th wh j ch they &re met ^fa has iyen 
already formed in it ; a deposit of fat has . . . . r n i 1 • , r»,i 

also taken place. Magn. 20 di. rise to their being called ligaments of the 

lung, as if they formed a normal con- 
stituent of the organ. The manner in which the new vessels, that we 
at a very early stage perceive in the exudation, are produced, has been 
the subject of much discussion, the arguments adduced being based upon 
physiological experiments or direct observations, according to the in- 
quirer's bias. The course of the new vessels is generally less tortuous, 
and presents more parallelism than the vascular channels of the pleura ; 

1 Lectures on the Morbid Anatomy of the Serous Membranes, vol. i. p. 42. 




PLEURITIS. 437 

they appear to be active agents in effecting the absorption of a portion 
of the exudation matter, and after awhile a retrograde process ensues, 
and they in part cease to exist. The earliest trace of vessels which 
we have ourselves discovered in a case of acute pleuritic effusion occu- 
pying the base of one lung, where, as yet, no adhesions had taken place, 
and the creamy effusion was yet eminently fibrinous, exhibited the 
appearance of small coils, near the edge of the lymph, closely resembling 
a renal Malpighian tuft, into which two vessels could be seen entering ; 
the sharp outlines of the formations, and a somewhat lighter tinge than 
the surrounding fibrin, alone marked them ; they contained no blood 
corpuscles, and it was, therefore, only by inference that they were con- 
cluded to be young vascular channels. Dr. Hodgkin's view is that the 
new vessels are formed by the minute bloodvessels of the inflamed part 
becoming distended, and that their delicate parietes, and the structure 
through which they ramify become softened, and, yielding to the pres- 
sure of the blood in the distended vessels, give way at numerous minute 
points; he considers that the very small quantity of blood thus escaping 
from its vessels does not diffuse itself, but is received into the soft sub- 
stance of the false membrane, which accordingly exhibits numerous 
bloody points on the surface when detached from the serous membrane. 
That the vis a tergo of the general vascular current is an element in the 
distribution of the blood to the false membranes, cannot be doubted ; 
but we must demur to the view that it is diffused at random into the 
exudation matter, and then, as it were, prepares its own channels. The 
thickness of the false membrane varies from a delicate film to many 
lines ; it may itself become the seat of secondary inflammation, but in 
most cases it exerts a repulsive influence upon fresh attacks, and assists 
in protecting the adjacent parts from encroachment. A marked instance 
of this occurred under our observation lately, in an old man who had 
suffered a fracture of seven ribs of the left side, followed by inflam- 
mation of the corresponding pleura. The two surfaces of the upper 
half of the pleural sac had formed intimate adhesions, and the subjacent 
pulmonary parenchyma had remained in a healthy condition; the lower 
half contained two and a half pints of turbid serum ; there was a thick 
layer of false membrane on the corresponding half of the lung, and this 
part of the organ was rendered unfit for respiration by the inflammatory 
process transmitted to it. 

The amount of liquid effusion resulting from pleurisy varies from the 
smallest appreciable quantity to as much as twelve pints. A case, in 
which this amount was removed from a man aged 3-3, by paracentesis 
thoracis, is given by Dr. Novarra, in the Medical Repository for 1&20. 
Dr. Hodgkin 1 details an interesting case of empyema, which partly dis- 
charged itself through the bronchi, and in which, after death, three large 
basins were filled with the sero-purulent contents of one pleural sac. 

Liquid effusion necessarily induces not only compression of the lung 
on the affected side, pushing it upwards, but also displaces the adjoining 
viscera ; the heart is forced over to the right thorax when the effusion 
is into the left pleural cavity ; if into the right, the liver is depressed ; 

1 Lectures on the Morbid Anatomy, &c. vol. i. p. 121. 



438 PLEURITIS. 

in both cases the diaphragm is forced down, and its movements interfered 
with, while the intercostal spaces of the affected side exhibit a marked 
prominence, and the ribs are maintained in an elevated position. These 
anatomical features of extensive pleuritic effusion can scarcely be too 
strongly insisted upon in the bearing they have upon diagnosis. How- 
ever, we must bear in mind that exceptional cases occur, in which, owing 
to a partial reabsorption of the fluid having been effected, the symptoms 
above detailed are not always so marked as to render the diagnosis easy. 
Laennec observes that, at the epoch at which we ought to operate, the 
affected side, though full of pus, is less than the healthy side, owing to 
this circumstance and the consequent falling in of the parietes. 

The secondary changes resulting from firm adhesion being formed are 
of a different character. If they have been associated with previous 
extensive effusion, which has become absorbed, the degree to which the 
compressed lung will regain its former functions depends upon the dura- 
tion of its confinement, and upon the firmness of the adhesions. The 
immediate consequence of the absorption was first shown by Laennec to 
be a falling in of the affected side, owing to the expansion of the lung 
not taking place in the ratio of the removal of the liquid ; and the 
firmer the adhesions are at given points, the more will this tendency be 
promoted by their increasing density and contraction. The depression 
is generally most marked at the lower part of the thorax, about the 
seventh and eighth ribs ; and, owing to the consequent atrophy of the 
respiratory muscles of the affected side, the equilibrium is destroyed, 
and the spinal column is deprived of its symmetrical support ; from this 
a curvature of the spine results, the convex margin of which is directed 
towards the healthy side. The shoulder of the diseased side sinks in 
proportion. A falling in of the upper portion of the thorax, or of the 
infra-clavicular region, is commonly noticed as an accompaniment of 
phthisis, consequent upon the formation of extensive cavities, and the 
coincident thickening and contraction of the pleura, to which we have 
alluded when speaking of tubercular disease of the lungs. 

There is no affection with which tubercular phthisis is so commonly 
associated as adhesions between the pleural surfaces, and the relation 
the two bear to one another appears to be in the ratio of the extent of 
the former. Hence, the pleurisy has both a chronic and a more local 
character, and must be set down to the secondary irritation arising after 
the deposit has been effected. The gradual thickening assumes a carti- 
laginoid consistency, and the union becomes so intimate that considerable 
force is often required to remove the lungs, and it is scarcely effected 
without laceration of their tissue. The intercurrent pleurisy accom- 
panying tubercular disease of the lungs is the source of those flying 
pains which, from time to time, attack phthisical subjects. The frequency 
of its occurrence is best illustrated by the statement of Louis, that, in 
one hundred and twelve phthisical subjects, he found but one whose lungs 
were perfectly free in every point of their surface. In eight cases only, 
he found the right pleura wholly unattacked, and in seven the left ; in 
these cases there were either no cavities in the non-adherent lung, or they 
were very small. Irritation, proceeding from other parts, may equally 
give rise to partial pleurisy; thus, we find it limited to the diaphragmatic 



EMPYEMA. 439 

surface, in relation with a diseased liver, spleen, or peritoneum. Irri- 
tation of the mediastinal portion may be excited by morbid affections of 
the heart or bronchial glands ; a limited effusion is frequently observed 
connecting the interlobular fissures, especially in connection with pneu- 
monia and tubercular irritation. 

The proclivity to pleuritis is greatest about the middle period of life, 
and diminishes in the ascending and descending scale of age. Before 
the fifth year, it is not often met with. Dr. West observes that acute 
idiopathic pleurisy, unconnected with pneumonia, or in which the inflam- 
mation of the lung bears but a very small proportion to that of the pleura, 
is certainly an uncommon affection during the first years of childhood, 
and as a cause of death its rarity is extreme ; and it certainly has ap- 
peared to us that, in cases of pneumonia, there is decidedly a less tend- 
ency, in early life, to excite pleuritic inflammation than we should observe 
in corresponding affections of a later period. With regard to chronic 
pleurisy, Dr. West remarks, "that, while it is a very rare occurrence as 
a purely idiopathic affection in early life, it is one of the most common 
complications of the dropsy which often succeeds to scarlatina." 

We do not generally find extensive pleurisy affecting both sides at the 
same time, while there is a marked difference in regard to the tendency 
of either pleura to inflammatory attacks, the left side presenting a 
much greater proclivity than the right. Hasse certainly states that the 
two sides are equally prone, but considers the fatality to be greater 
when the left side is attacked, than when the inflammation affects the 
right. The thirty-five fatal cases which he observed, were distributed 
in the following manner: nine were double pleurisies, and in five out 
of the nine, the affection was trifling on one side; in the remain- 
ing twenty-six, the left side was the seat sixteen, the right ten times. 
He also quotes Mohr's experience, who found that of fifty-six cases, 
the left side was the seat thirty-seven times ; the right, nineteen times. 
Drs. Hamilton Roe, Hughes, and Copland, are also of opinion that 
the. disease exhibits a much greater frequency on the left than on 
the opposite side of the thorax. It appears from the observations of 
Messrs. Rilliet and Barthez that the converse is the prevailing character 
of infantile pleuritis, and that in children the right side is more liable 
to the idiopathic affection than the left. 



EMPYEMA. 

We have stated above that the more chronic the form assumed by 
inflammation of the pleura, the greater the tendency to liquid effusion. 
Some authors assume that, in these cases, the plastic matter first thrown 
out may be subsequently converted into pus, a point which has not been 
determined by direct observation, and certainly is not sufficient to ac- 
count for the enormous accumulations that sometimes take place. The 
chronic forms are frequently marked in such a way as to deserve the 
term of latent pleurisy ; the symptoms, in the first instance, apparently 
indicating disease in an organ unconnected with the thoracic cavity. It 
is here that, during life, the value of the stethoscope is particularly 



440 EMPYEMA. 

manifested, as its application will at once remove the difficulties of 
diagnosis. It is to the chronic effusion of a serous or sero-puriform fluid 
that the name of empyema is properly applicable, and the inorganizable 
nature of the pleural contents in these cases is dependent upon dimi- 
nished tone and vigor of the constitution. The solid matter, according 
to the views expressed by Dr. C. J. B. Williams, "is thrown out in a 
disintegrated state, utterly insusceptible of organization, and diffused 
through the fluid in flakes or particles, forming a mixture more or less 
resembling pus, although in many instances this is the result of a more 
chronic form of pleurisy than that which forms lymph, and owes its 
increase and persistency to the want of vitality in its solid matter. Yet 
we do meet with cases of empyema which arise from very acute forms 
of inflammation. In these instances the fluid is more strictly purulent, 
the solid matter being in the form of globules like those of pus, and 
seems to be the result of what may be called a suppurating diathesis, in 
consequence of which all the albuminous products of inflammation tend 
to assume a purulent character." A marked difference exists between 
the pleura and peritoneum in regard to this point, for, while the former 
is peculiarly liable to effusions resulting from a low form of inflamma- 
tion, the fluid accumulations that we meet with in the latter are more 
often of a mechanical origin; hence, the result of operative interference 
is very much more favorable in cases of empyema and inflammatory 
hydrothorax than in ascites ; in the former, when the diseased condi- 
tion giving rise to the effusion has subsided, there does not exist a tend- 
ency to repeated accumulation as in the latter ; hence, paracentesis 
thoracis is more likely to prove a curative agent than tapping of the 
abdomen, where it rarely serves otherwise than as a means of palliating 
urgent symptoms. Dr. Hamilton Roe, who has disproved Laennec's 
statement, that paracentesis was rarely successful, obtained a recovery 
in eight out of nine cases of empyema, and of nine out of thirteen of 
inflammatory hydrothorax; and in the same paper from which we derive 
this information, 1 we find that Mr. B. Philips records a brief analysis of 
122 cases of paracentesis, thirty-one of which were performed for em- 
pyema, and nine for hydrothorax ; of the former twenty-six, of the latter 
six were cured. 

It is, however, admitted on all hands, that it is essential to the suc- 
cess of paracentesis thoracis that it be performed at an early period of 
the disease. 

When the fluid is not evacuated by an operation, it is occasionally dis- 
charged spontaneously, either by perforation of the pulmonary tissue, 
by the thoracic parietes, or by the diaphragm. Dr. Williams considers 
the second, while Laennec and Hasse look upon the first as the more 
frequent occurrence. The perforation of the intercostal spaces takes 
place, not as would be expected, at the base of the lung, but about the 
middle lobe of the lung; the discharge externally generally being 
effected by sinuous openings burrowing under the integuments. The 
prospect of recovery is greater here, than when perforation of the pul- 
monary pleura leads to an effusion into the lung ; for, in the latter 

1 Medico-Chirurgical Transactions, vol. xxvii. 



PNEUMOTHORAX — HYDROTHOKAI. 441 

instance, in addition to the mechanical influence of the fluid filling the 
bronchi, we have to deal with the contamination of the system likely to 
result from the decomposition of the fluid produced by its contact with 
the atmosphere. 

PNEUMOTHORAX. 

This forms one of the modes by which pneumothorax, or the accumu- 
lation of air in the pleural cavity, is produced. The most frequent 
origin of this condition, however, is perforation of the pulmonary pleura 
by the extension of a tubercular cavity, before the opposing surfaces 
have become agglutinated by fibrin ; the mere softening of one or two 
tubercles formed close to the pleura, and communicating with a minute 
bronchus, is described by Dr. Copland as another, though rarer cause 
of this accident. It has been found to result from rupture of emphyse- 
matous vesicles ; and Rokitansky also states that it may be consequent 
upon perforation of the diaphragm or of the mediastinum, arising from 
acute softening of the stomach or oesophagus. That perforation of the 
superficial parts leading to the pleural sac induces pneumothorax, will 
be naturally inferred at once ; but it is very improbable that it is ever 
due to the evolution of gases from the fluids of hydrothorax by sponta- 
neous decomposition, until after death. The perforation leading into 
the pleural sac is generally a small oval aperture, or a mere fissure, a 
few lines in length, and situated in the vicinity of the third and fourth 
ribs near the axilla. The left side offers the greatest liability ; Louis 
found it affected in seven out of eight cases ; Hasse has met with nine 
in which the left, and seven in which the right side was the seat of the 
lesion ; and of fifty collected by Reynaud, thirty-three were on the left 
and seventeen on the right side. The immediate result of the perfora- 
tion is imminent, if not actual suffocation from collapse of the lung ; if 
death does not at once ensue, intense pleuritis is set up, and the patient 
rarely survives for many days. We find the lung compressed to the 
utmost, and the other viscera are much displaced, according to the side 
in which the air has accumulated, the epigastrium protruding from the 
descent of the diaphragm, and its action on the liver and stomach ; the 
other pathological conditions are those indicating inflammation of the 
pleura ; and we may observe an attempt at repair in the shape of a 
false membrane investing the fissure. The occurrence of pneumothorax 
is only possible when the pleura "at the point of perforation has not 
previously become adherent ; but it sometimes happens that the ulcera- 
tive process is continued after the pulmonary and parietal pleura have 
been agglutinated, and passing through the uniting medium attacks the 
intercostal muscles and integuments. A fistulous opening may thus be 
established. 

HYDROTHORAX. 

Hydrothorax, or dropsical accumulation of fluid in the pleural sac, 
occurs in two forms, as a primary and as a consecutive lesion ; the for- 
mer is a disease of much less frequent occurrence than was at one time 



442 HEMOTHORAX — GANGRENE. 

supposed. Laennec states that one could not establish a higher ratio 
for the occurrence of idiopathic hydrothorax as a cause of death, than 
one in two thousand. Let us hope that the days are past in which such 
errors of diagnosis, as he alludes to, can be committed ; for he asserts 
having found hypertrophy of the heart, aortic aneurism, phthisis pul- 
monalis of a somewhat irregular character, and even scirrhus of the 
stomach or liver, without the least effusion into the pleura, mistaken for 
hydrothorax. The affection consists in the effusion of a limpid serosity 
into the pleura, to a greater or less amount, generally limited to one 
side, and unaccompanied by any appreciable change of structure in the 
serous membrane ; the compression exerted by the fluid upon the lung 
and the adjacent parts, is necessarily the same in this instance as in 
those forms of fluid accumulation which have already been considered. 

The secondary or symptomatic form of hydrothorax is a common 
sequel of acute or chronic diseases, heralding the fatal termination, and 
giving evidence of that loss of tonicity that results from exhaustive 
maladies. The circulating system is more frequently found to be at 
fault than any other ; hypertrophy of the heart, valvular disease, peri- 
carditis, are common causes ; it is also often associated with renal de- 
generations, tubercular and cancerous affections. The same cause that 
induces the effusion into the pleura, gives rise to dropsical accumulation 
in other serous cavities, or in the cellular tissue ; hence symptomatic 
hydrothorax is generally accompanied by other affections of the same 
kind. As in the primary form, we find no definite lesion of the serous 
surface associated with it ; it is not in fact an affection of the membrane 
at all, but exclusively of the vascular system, and we must look to the 
blood and the capillaries for an explanation. According to Laennec, it 
rarely occurs more than a few days before death ; and though it often 
produces no sensible effect upon the patient's feelings, it often causes 
suffocative attacks, which render his last moments painful amd distress- 
ing. The liquid itself is commonly a clear straw-colored serum. 



HEMOTHORAX. 

When the pleural sac is filled with blood, or with a fluid of a de- 
cidedly sanguineous character, we have to deal with hsemothorax. This 
is commonly due to some mechanical lesion or to the rupture of an 
aneurism ; but it has also been met with as the result of capillary ex- 
halation — of the same character as that to which active or passive 
spontaneous hemorrhages are commonly attributable. It is said to be 
capable of reabsorption or to superinduce inflammatory action ; or, 
again, to be liable to decomposition, and thus to give rise to pneumo- 
thorax. 

GANGRENE. 

Before considering the adventitious products met with in the pleura, 
we must briefly advert to the occurrence of gangrene. It is an unusual 
lesion, and is commonly connected with gangrene of the pulmonary 



ADVENTITIOUS PRODUCTS. 443 

tissue. The sloughs are to be recognized by their greenish brown or 
blackish hue, of a circular or irregular form, extending to some distance 
beyond the part detached. The fetid smell will also assist in deter- 
mining the character of the lesion. 



ADVENTITIOUS PRODUCTS. 

Among the homologous formations occurring in the serous membrane 
of the lungs, authors enumerate cartilage, bone, and fat. A cartilagi- 
noid thickening of the pleura, more especially at and about the apices, 
is by no means unusual ; but the microscope invariably resolves this 
deposit into one of a fibrous, or, as Lebert terms it, chondroid, charac- 
ter. If the result of gone-by inflammation of the pleura, it affects the 
free surfaces of the membrane with which it intimately coalesces : when 
due to subserous congestion, it is found in the subserous tissues, and in 
the membrane itself. The lung exhibits fibroid formations, which, like 
those found on the heart, the liver, or the spleen, are frequently but the 
indications of a fibrinous blood crasis, independent of any actual inflam- 
matory process ; they are smoothed, nodulated, very dense, and adherent 
only by their exterior surface. We meet with the formation of true 
bone in the pleura as little as of genuine cartilage : the osteoid deposits 
are mere amorphous aggregations of calcareous matter, occurring in 
plates or irregular points ; they may be encysted, and occasionally they 
form pedunculated projections invested by the pleura. To this class we 

Fig. 203. 




Old eartilaginoid capsule of the apex of a lung, in a man aged 63 ; both lungs were similarly affected, and 
like patches were also found on the spleen. There was some appearance of obsolete tubercle, and much black 
pigmentary matter. No definite structure was to be traced in the capsule by the microscope. 

may probably refer the case of ossification of the lungs given by Dr. 
Baillie, 1 for, in the delineation, the ossified parts are distinct polypoid 
offsets from the pulmonary tissue, though apparently invested by the 

1 Morbid Anatomy, Second fascic. pi. vi. 



U4: 



ADVENTITIOUS PKODUCTS. 



same membrane. Rokitansky states that fibrous exudations invest the 
costal as well as the pulmonary, but that they only ossify on the costal 
pleura, the subserous products occurring chiefly in the intercostal spaces, 
from which they may be discharged into the cavity of the thorax in the 
shape of round nodules. That ossification of the pleura is generally 
preceded by some inflammatory condition, may be inferred both from 
the frequent occurrence of other inflammatory products in the pleura, 
and from the analysis of a considerable number of cases in a disserta- 
tion by Dr. Posselt ; J he found that out of twenty-seven instances twelve 
affected the right, and fifteen the left side, while the ratio of the sexes 
was as thirty men to four women. The size of the osteoid deposit is 
occasionally very extensive. Dr. Hodgkin removed from an old man 
who died at Guy's Hospital, a plate of bone subjacent to the parietal 
pleura, which half encircled the chest and formed a considerable mass. 
The fatty deposits which we find connected with the pleura are rarely 
on the free surface, but seem to be the result either of a transformation 
of previous inflammatory products, or a fatty growth under a false 
membrane. Recent fibrinous exudation occasionally closely resembles 

Fig. 204. 




Fig. 205. 






©; 




Naked-eye and microscopic view of cancer of the pleura. The growths were mainly in the interlobar 
fissures, and occurred in a female who had malignant disease of the left mamma. The liver also exhibited 
cancer-nodes. 

adipose tissue both in color and form, though there can be no real diffi- 
culty in determining its nature. Tubercular deposit is not often met 
with in the pleura ; and almost exclusively occurs as a secondary form 



1 De Pleurae Ossificatione, Heidelberg, 1839. 



ADVENTITIOUS PRODUCTS. 445 

of the disease. The pleura, in this respect, differs in a marked manner 
from the peritoneum and the arachnoid, both of which are more prone 
to primary tuberculosis than the former. Tubercle forms either under 
the pleura or in the sac — in the latter case, its seat is invariably in a 
false membrane ; tubercles of this description, Dr. Hodgkin remarks, 
when thickly set, have been mistaken for thickening of the pleura itself. 
Pleural tubercle, according to Rokitansky, not unfrequently softens and 
gives rise to tuberculous abscesses in the different pseudo-membranous 
structures in which it is deposited ; these abscesses may penetrate the 
pleura, and even the thoracic walls. 

Malignant growths never affect the pleura primarily, but involve the 
membrane by extension from the mamma, the bronchial glands, the 
mediastina, or other neighboring tissues. They appear on the pleura as 
flattened masses, rarely larger than an almond, surrounded by a halo of 
bloodvessels. While tubercle occurs in very numerous small spots, 
spread all over the membrane, cancer is only seen in a few isolated 
patches. Both are liable to induce serous effusion of a sanguinolent 
character. Medullary carcinoma and melanotic cancer are the forms of 
malignant disease that most frequently attack the pleura. 

Hydatid cysts appear to occur in the pleura. Cruveilhier 1 details a 
case in which a large number of acephalocysts w r ere discharged from 
an artificial opening, apparently communicating with the pleural cavity, 
in a whitesmith, aged 29; the man entirely recovered, after the evacua- 
tion of above five hundred hydatids. Dr. Hodgkin, 2 in his fifth lecture, 
speaks of a specimen presented to Guy's Museum, in which a large cyst 
containing acephalocyst hydatids is situated in part beneath the close 
pericardium about the base of the heart, and partly under the pleura 
pulmonalis, at the root and summit of the right lung. 

1 Anatomie Path ologi que, vol. i. p. 247. 

2 Morbid Anatomy of the Serous Membranes, vol. i. p, 137. 






THE PATHOLOGICAL ANATOMY OE THE 
ALIMENTARY CANAL. 



CHAPTER XXXII. 

I. OF THE MOUTH AND FAUCES. 

Congenital malformations sometimes consist in an excess of the 
natural number of parts, so that the jawbones, "the mouth, and the 
tongue, are double, and unite in one common gullet." More often they 
show themselves by defective formation of the mouth and fauces (astomia), 
of the upper jaw (ateloprosopia), of the lower law (agnathia and atelog- 
nathia), of the lips (achelia and ateloehelia), of the tongue (ateloglossia). 
Arrest of development shows itself in the common single or double 
harelip, the fissure existing at the union of the intermaxillary with the 
upper jawbones; in fissures of the hard and soft palate; in fissures of 
the tongue, the lower lip, and the lower jaw, which are all very rare. 
In some rare instances, the orifice of the mouth is wanting [atresia oris). 

The buccal mucous membrane shows but little tendency to be affected 
by catarrhal inflammation; it is, however, often inflamed in one or more 
spots from some local irritation, or morbid action. Thus, a carious 
tooth, a piece of diseased bone, a crop of ulcerations, will excite inflam- 
mation in their vicinity. In adults, general inflammation of the mucous 
membrane is sometimes produced by the abuse or excessive action of 
mercury, and shows a marked tendency to pass into a state of ulceration 
and sloughing. Mr. Tomes mentions the occasional occurrence of spon- 
taneous salivation, with considerable inflammation of the gums. Chronic 
inflammation of the gums is not uncommon, and has appeared to us 
sometimes to be of rheumatic origin. It may extend over the whole 
mouth, or be confined to the vicinity of two or three teeth. "The 
surface of the gums," Mr. Tomes says, "becomes minutely nodulated; 
and the secretion of epithelium increased; the papillae are increased in 
prominence, while the substance of the gum is generally thickened, and 
the edges about the teeth become thick and round." 

In another form of so-called chronic inflammation, the gum rather 
ecreases in size, and " assumes a very smooth and polished surface, and 

ottled aspect;" the hard palate also becomes implicated, and there is 
cute intermittent pain. Ulcerations often form on the gums, as well 



448 THE MOUTH AND FAUCES. 

as on other parts of the mucous membrane of the buccal cavity ; they 
are sometimes simple aphthae, sometimes small, round, slightly excavated, 
and without any surrounding inflammation. In some cases, the ulcera- 
tions are attended with much inflammation, and swelling of the mucous 
membrane and subjacent tissues, and, in others, they are rather of a 
sloughy nature, and form upon a surface dark colored by asthenic con- 
gestion. 

Epulis (eiti, ov'kov) is a fibrous tumor, which originates in the fibrous 
tissue of the gums, or in the periosteum, and not only grows outward 
toward the cavity of the mouth, but also penetrates into the Haversian 
canals and cancelli of the bone. Its surface is generally pretty smooth, 
"like the gum," or it may be rough and more or less lobulated. "Osseous 
spiculse not uncommonly shoot," according to Mr. Tomes, " from the 
surface of the jaw into the tumor, and, in some cases, isolated nodules of 
bone (calcification?) are found in the substance." Polypus of the gum 
is a local hypertrophy of its tissue, occasioned by some mechanical irri- 
tation. It shows, " on section, an undulating fibro-cellular tissue, covered 
by a thick layer of epithelium." Vascular tumors, consisting essentially 
of dilated vessels, sometimes appear on the gums. Mr. Tomes describes 
one of a bright scarlet color, soft in texture, and easily compressed and 
emptied of blood, and prone to bleed on slight irritation. Cancer, almost 
always in the form of scirrhus, occasionally attacks the gums. Its size 
varies usually from that of a pea to that of a nut. It ulcerates after a 
time, and may throw out fungous growths. 

The vesicles of herpes, and the pustules of variola, occasionally are 
developed upon the buccal mucous membrane. 

The croupy process (the diphtheritis of Bretonneau) appears in adults, 
according to Rokitansky, in two forms. In one, " after a previous vivid 
or dark purple reddening of one or more papillae, and the vesicular 
elevation of the epithelium at the point and the sides of the tongue, dots 
or patches, of the size of a lentil or pea, appear on the inner surface of 
the lips and cheeks, and, finally, on the mucous membrane of the fauces. 
They present an exudation which has a frosted, or flocculent, or villous 
appearance, or is more of a membranous character, and extends into the 
cavities of the follicles ; it is of a grayish, or yellowish-white color, and 
of a lardaceous, or soft, creamy, or fluid consistency ; if removed, a 
shallow, excoriated depression, surrounded by an inflamed margin, re- 
mains, on which the exudation is repeated, involving a further destruction 
of the mucous tissue. In the second instance, livid spots, which rapidly 
coalesce, and become invested with a dirty, gray, shaggy, pultaceous, 
and sanious exudation, form upon the softened, bleeding gums, and the 
mucous membrane of the cheeks, the fauces, and the tonsils. The gums 
themselves ultimately degenerate into a bad-looking, pulpy, sanious mass, 
and the mucous membrane of the cheeks and fauces, underneath the 
exudations, is equally found converted into a friable fetid pulp, or a 
firm slough." The epidemic adynamic character of the above described 
process, is now well known. Andral, writing more than twenty years 
ago, contended most justly that the congestion of the part affected, though 
first in order, was but secondary in regard to casual agency ; and Roki- 
tansky's investigations of the different kinds of intra and extra-vascular 



THE MOUTH AND FAUCES. 449 

fibrin, which we have before noticed, have made it almost certain that 
the essence of the disease consists in an alteration of the liquor sanguinis, 
which gives rise to unhealthy exudation from the bloodvessels at various 
parts. Andral mentions that blistered and all denuded surfaces, during 
the prevalence of such epidemics, become covered with false membranes 
like those which form on mucous surfaces. Wounds and ulcers at such 
periods are found unusually inapt to heal, and all experience of the 
juvantia and laedentia, seems to testify that the local morbid process is 
extremely different from common inflammation, and is essentially de- 
pendent upon a grave alteration of the general system. The color of 
the exudation, which is naturally whitish, is often rendered darker by 
sanguineous effusion saturating it; when this is the case, its aspect, and 
the extreme fetor which it exhales, give to it a considerable resemblance 
to a gangrenous slough. This would be still more increased if it were 
situated, as it sometimes is, beneath, and not upon the layer of epithelium. 
The succeeding kinds of ulceration which we shall describe are, for 
the most part, seen in children. Aphthae are small whity specks, some- 
times so closely set together that they coalesce and form patches, which 
may be very extensive. They separate after a time, leaving the mucous 
membrane beneath either simply excoriated, or superficially ulcerated. 
After being detached they are often produced again, and this may 
occur several times in succession. It is not yet quite decided of what 
these specks really consist; analogy would support the olden opinion 
of their being simply a variety of false membrane, but some microsco- 
pists contend that they are solely clusters of parasitic fungi. We in- 
cline with Dr. West to the belief that the former opinion is the more 
correct, not that we doubt the correctness of the observation of a growth 
of fungi in the exudation, but that we think it much more probable that 
these are developed secondarily in an unhealthy, aplastic, animal mat- 
ter, which is freely exposed to the contact of air. Dr. West suggests 
the idea that the sporules of this fungous growth might, by lighting 
upon the mucous membrane, and exciting irritation there, cause the 
production of the aphthous specks. This, we think, is very improba- 
ble, as, were this the case, but few children could hope to escape : the 
diffused sporules which affect one child, might as well affect all who were 
at all disposed. It should be mentioned that the term muguet is applied 
by the French to the more extensive deposits of this kind. Bad health, 
indigestion, or abdominal disorder are the precursors and attendants on 
aphthae. The whole of the buccal mucous membrane appears to be in 
a state of asthenic inflammation, and the same condition extends in 
some measure to the whole alimentary track. The disorder is, certainly, 
a general One, manifesting itself by a local symptom, and not confined 
to that part. Adults are sometimes affected by aphthae as the result of 
indigestions, or as indicative of decaying vital powers. A late eminent 
physician prognosticated his own approaching decease from the appear- 
ance of aphthae on his tongue. Dr. H. Salter describes small circular 
ulcers which form at the tip and along the edges of the tongue. These 
we have experienced ourselves, and can scarce think they should be 
separated from aphthae. According to him they are produced by the 
29 



450 THE MOUTH AND FAUCES. 

effusion of lymph into one of the fungiform papillae, which soon disap- 
pears by sloughing or ulceration, leaving an ulcer which continues to 
spread for some time. 

Follicular stomatitis is described by Dr. West as sometimes idiopathic, 
sometimes a concomitant of measles. In either case it is rare, after 
five years of age. " The mouth is hot; its mucous membrane generally 
of a livid red, while a coat of thin mucus covers the centre of the tongue. 
On the surface of the tongue, especially near its tip on the inside of the 
lips, the cheeks, near the angles of the mouth, and less often in other 
situations, also, may be seen several small, isolated, transparent vesicles 
on the ulcers, which, after bursting, they leave behind. The ulcers are 
small, of a rounded or oval form, not very deep, but having sharply cut 
edges ; and their surface is covered by a yellowish white, firmly-adhe- 
rent slough." " When the ulcers are healing, no change in their aspect 
is observable, and they continue to the last covered by the same yellow 
slough, but, by degrees, they diminish in size ; and seldom or never is 
any cicatrix observable in the situation which they occupied." The 
vesicles form in crops, not generally containing many ; the resulting 
ulcers sometimes coalesce and form a continuous patch. The affection 
is sometimes complicated with herpes of the skin of the lips, and might 
almost be considered as a similar eruption of the mucous surface. 

In ulcerative stomatitis, as described by the same observer, " the 
gums are red, swollen, and spongy, and their edge is covered with a dirty 
white or grayish pultaceous deposit ; on removing which their surface is 
exposed, raw, and bleeding. At first only the front of the gum is thus 
affected ; but as the disease advances, it creeps round the teeth to their 
posterior surface, and then destroying the gum, both in front and behind 
them, leaves them denuded, and very loose in their sockets. On those 
parts of the lips and cheeks, however, which are opposite to, and conse- 
quently in contact with, the ulcerated gums, irregular ulcerations form, 
which are covered with a pultaceous pseudo-membranous deposit, similar 
to that which exists on the gums themselves. Sometimes, too, deposits 
of false membrane take place on other parts of the inside of the mouth, 
the surface beneath being red, spongy, and bleeding, though not dis- 
tinctly ulcerated. . . . When recovery has commenced, the disease 
ceases to spread ; the drivelling of fetid saliva diminishes ; the white, 
pultaceous deposit on the gums, or on the ulcerations of the cheek or 
lips, becomes less abundant; the ulcers themselves grow less; and, 
finally, the gums become firm," and slowly, and perhaps with partial 
relapses, regain their healthy condition. The disease is common, rarely 
fatal, rarely associated with, or proceeding to gangrene. It is some- 
times designated by the term Noma. 

True gangrene of the mouth is a much less frequent, and much more 
fatal affection. It is very seldom idiopathic, almost always occurring 
consecutively to measles or some other disease. Messrs. Rilliet and 
Barthez found, out of twenty-nine cases, nineteen aged from two to five 
years, and ten aged from six to twelve. We again quote Dr. West's de- 
scription, which pictures very well the only case which we have witnessed 
ourselves. There is at first scarce any suffering, and some unusual fetor 



THE MOUTH AND FAUCES. 451 

of the breath, some profuse secretion of offensive saliva, and swelling of 
the cheek, are the first circumstances which are observed. The characters 
of the swelling of the cheek are almost pathognomonic. It is not a mere 
pufliness, but is tense, red, and shining — looking " as if its surface had been 
besmeared with oil, and in the centre of the swollen part there is gene- 
rally a spot of a brighter red than that around. The cheek feels hard, 
and is often so unyielding, that the mouth cannot be opened wide enough 
to get a good view of its interior. The disease is almost always limited 
to one side, and generally to one cheek." Occasionally, it begins in the 
lower lip, never in the upper, but it may extend to either. " Whatever 
be the situation of the external swelling, there will generally be found 
within the mouth, at a point corresponding to the bright red central 
spot, a deep excavated ulcer, with irregular jagged edges, and a surface 
covered by a dark, brown, shreddy slough. The gums opposite to the 
ulcer are of a dark color, covered with the putrilage from its surface, 
and in part destroyed, leaving the teeth loose, and the alveolse denuded. 
Sometimes, especially if the disease be further advanced, no single spot 
of ulceration is recognizable, but the whole inside of the cheek is occu- 
pied by a dirty putrilage, in the midst of which large shreds of dead 
mucous membrane hang down. As the disease extends within the cheek, 
a similar process of destruction goes on upon the gum, and the loosened 
teeth drop out one by one. The saliva continues to be secreted pro- 
fusely, but shows by the changes which take place in its character the 
progress of the disease. At first, though remarkable for its fetor, it is 
otherwise unaltered, but afterwards loses its transparency, and receives 
from the putrefying tissues over which it passes, a dirty, greenish, or 
brownish color, and at the same time acquires a still more repulsive odor. 
While the gangrene is thus going on inside the mouth, changes no less 
remarkable are taking place on the exterior of the face. The redness 
and swelling of the cheek extend, and the deep red central spot grows 
larger. A black point appears in its midst; at first, it is but a speck, 
but it increases rapidly, still retaining a circular form — it attains the 
bigness of a sixpence, a shilling, a half-crown, or even a larger size. A 
ring of intense redness now encircles it, the gangrene ceases to extend, 
and the slough begins to separate. Death often takes place before the 
detachment of the eschar is complete ; and it is fortunate when it does 
so, for sloughing usually commences in the parts left behind. The inte- 
rior of the mouth is now exposed, its mucous membrane and the sub- 
stance of the cheek hang down in shreds from amidst a blackening 
mass," which exhales a horrible fetor. There is no acute pain through- 
out, the patient is generally rather drowsy, and death takes place quietly 
in most cases. No cause has been assigned for the occurrence of gan- 
grene in this part; all that can be said is that a true mortification or 
death of the textures seem to take place, which is itself the primary evil, 
and not the result of inflammation, disease of the vessels, or obstruction 
of their channels. This is a good illustration of the doctrine we main- 
tained, when speaking of mortification, viz : that it essentially con- 
sisted in a loss of the vital powers which maintain, in opposition to those 
of inorganic chemistry, the complex constitution of the animal tissues. 



452 THE MOUTH AND FAUCES. 

The tongue is liable to be affected by inflammation, or glossitis, as it 
is termed. This in some rare cases, said by Dr. Salter to occur most 
often in scrofulous persons, causes the formation of abscess. On the 
matter being evacuated, the tongue speedily returns to a healthy state. 
Sometimes a partial inflammation of the tongue is met with, the morbid 
process being confined to the portion of the base bounded in front by 
the V-shaped line of circum vallate papillae. It occurs as an extension 
of tonsillitis, which we shall presently notice. Deglutition in these 
cases is seriously interfered with. The inflammation of the gums, which 
is produced by mercury, sometimes involves the tongue, and occasions, 
in some cases, very great and rapid swelling. It does not seem to have 
even produced suppuration. One variety of glossitis has been dis- 
tinguished by the term erectile, by Dr. Salter. He describes " the mor- 
bid condition of the tongue in this disease as consisting in an enormous 
and rapid distension of the organ by blood, rendering it very large, 

Fig. 206. 




Tongue, swollen by Glossitis. 

hard, and stiff. The distension becomes so great that respiration through 
the mouth is quite prevented, and even can with difficulty be performed 
through the nostrils. Though the congestion becomes so intense that 
the organ is of a dark black color, neither mortification nor abscess 
appears to have ever taken place. Free incisions give exit to the blood, 
and recovery ensues. Sometimes one-half of the tongue only is affected. 
In most cases it occurs in persons who are in perfect health, and without 
any manifest exciting cause." 

Severe and deep ulcerations of the tongue may arise " from mere 
disorder of the alimentary canal," especially in debilitated persons. 
Some of these, attended with much induration, may bear a very close 
resemblance to cancerous ulcers. Constitutional syphilis produces small 
superficial circular ulcers, which sometimes extend in depth, and some- 
times in length only. Rhagades or fissures result from the same cause ; 
they often occupy the medium line in the front part of the organ ; they 
may be mere cracks, or extend three-quarters of an inch in depth, with 
irregular ulcerated edges. Often, they are associated with tubercles of 
the surface of the tongue. These, which are admirably described by 
Dr. H. Salter, under the name of glossy tubercle, appear to be of the 
same nature as the syphilitic tubercles termed gummata. Ricord speaks 
of them as deep-seated tubercles of the subcutaneous areolar tissue, a 



THE MOUTH AND FAUCES. 453 

kind of chronic furuncles ; and refers to two cases of recurring syphilis, 
in which the tongue was so full of them that it felt as if stuffed with 
nuts. According to the French observer, they produce horrible de- 
structive ulcerations. Dr. H. Salter describes them " to consist in an 
effusion of lymph into the cellular tissue underlying the mucous mem- 
brane ; this effusion is very dense, and raises and distends the surface 
of the tongue at the affected part above the surrounding portions ; the 
effect is that the papillae near it are opened out, and sometimes totally 
obliterated. Hence the surface of the tubercles is smooth, and, as they 
become absorbed, the papillse reappear again. 

The tongue is liable to be the seat of cancerous growths of the scir- 
rhous and epithelial species. The former is described by Mr. Travers 
as at first being an irregular rugged knob, generally situated in the 
anterior third, and midway between the raphe and one edge. Ulcer- 
ation sometimes takes place very rapidly ; the surface at the same time 
throwing out luxuriant fungous growths : in other cases it " is very 
uneven, clear and bright granulations appearing in parts, and in others 
deep and sloughy hollows." In a peculiarly interesting case of epithe- 
lial cancer, carefully watched by Dr. H. Bennett, the first appearance 
of the disease was a small ulcer on the margin of the tongue. This 
extended, in spite of its being shielded from the pressure of the teeth, 
and had hard, everted edges, undermined some way by ulceration. These 
became more ragged, and here and there over the surface some degree 
of suppuration and sloughing occurred. Much improvement followed 
the excision of the tumor — the wound healed favorably. Not long after, 
however, the glands under the jaws enlarged, and were removed ; and, 
in about nine months after this, the disease returned in the tongue and 
proved fatal. The morbid growth which had been removed presented, 
on a transverse section, a tract of white, indurated, convoluted structure 
immediately below the ulcer, and above the muscular substance of the 
tongue. This indurated tract was half an inch thick posteriorly, and 
consisted of a fibroid structure inclosing debris of muscular fibre, and 
some of the characteristic circular loculi of epithelial cancer. The surface 
of the ulcer was covered with papillary elevations, which consisted chiefly 
of enlarged, softened epithelial scales splitting into fibre, so as to form 
a kind of fringe. This history shows, we think, beyond any doubt, that 
what Dr. Bennett would distinguish as cancroid, are in many, if not 
most cases, as true cancers as any of the other species. The circum- 
stance mentioned by Dr. Bennett in his Appendix to his work is curious 
and significant, viz : that the enlarged glands beneath the jaw contained 
quantities of epithelial scales similar to those found in the primary 
growth. This indicates a potentiality in the blastema, absorbed from 
the epithelial tumor, to cause a reproduction of like cell-structure. 

Fatty tumors and simple cysts are occasionally met with in the tongue, 
and Dr. Salter mentions the occurrence of pediculated polypoid growths, 
which seem to be of the nature of fibrous tumors, or, perhaps, in some 
cases of enchondroma. The tongue is liable to be affected by an extra- 
ordinary hypertrophic enlargement, in consequence of which it protrudes 
from the mouth, sometimes as much as two and a half inches. The 



454 THE MOUTH AND FAUCES. 

structure is altered, becoming much more dense than natural ; but it 
has not been determined exactly in what the alteration consists. In 
one case, recorded by Mr. Liston, the enlargement of the organ seems 
to have been occasioned by the development of nasvus-like structure. 
Atrophy of the tongue only occurs as the consequence of paralysis, 
from division of the hypoglossal nerve, or attacks of hemiplegia. It is, 
of course, confined to the affected side. Dr. Salter gives an interesting 
account of the morbid changes which the lingual papillae undergo. The 
circumvallate papillae may be hypertrophied, and form little tumors as 
large as peas. The epithelial caps of the conical or filiform papillae 
may become extraordinarily elongated, so as to be half an inch long ; 
they are of a dark color, and look exactly like little brown hairs. 
Minor degrees of this condition are, we think, not uncommon. The 
papillae sometimes become atrophied. " Mr. Lawrence mentions the 
case of a person, in whom, from habitual drinking, the tongue was, for 
the greater part of its surface, destitute of papillse : it was white, smooth, 
and opaque on the surface." Blood and lymph may be effused into the 
substance of the fungiform papillae. The pus which so commonly col- 
lects on the surface of the tongue in disease, consists of detached, and 
more or less disintegrated epithelium, with varying proportions of amor- 
phous matter. We can corroborate Dr. Salter's statement, that, in 
some healthy persons, the tongue is habitually furred. In very rare 
cases the fraenum of the tongue is so short that it is quite tied down to 
the floor of the buccal cavity, and cannot perform its proper move- 
ments. Minor degrees of the same condition are not infrequent, and 
gradually improve of themselves. In the opposite condition, " the 
movements of the tongue are too free ; it can be inverted, and its apex 
thrown back into the pharynx, which embraces it," and thus the access 
of air to the lungs through the glottis is prevented. The sides of the 
tongue have been known to become closely adherent to the internal 
surface of the cheeks. 

The tonsils are a more common seat of inflammation and its conse- 
quences. In an acute attack they become more or less, sometimes 
enormously swollen, so as to impede the respiration. The pillars of 
the fauces, and the soft palate, are also involved in the inflammation. 
Suppuration often occurs, and is, perhaps, the best result, next to com- 
plete resolution; but more frequently, the imperfectly subdued hyper- 
aemia produces actual enlargement, and fresh attacks recurring, a chronic 
hypertrophy of the gland is the result. We have examined some en- 
larged tonsils which had been excised, and found their structure to be 
quite identical with that of the healthy gland, so that the alteration 
constituted a true hypertrophy. It seems worth while to notice briefly 
the structure of the tonsils, which we think is not well understood, as 
it explains in some measure their great liability to hypertrophic enlarge- 
ment. They are made up of a number of duplicatures and involutions 
of the mucous membrane, which, however, is differently constituted here 
to what it is in other parts in the vicinity. A vertical section shows 
the thin surface layer of scaly epithelium with a thick underlying 
stratum, consisting of nuclear, or very slightly developed celloid parti- 



MORBID CONDITIONS OF THE TEETH. 455 

cles. This layer is traversed by vessels, which are of capacious size in 
hypertrophied specimens, running up to the basement-membrane which 
supports the layer of scaly epithelium. When there is any habitual 
hyperemia, and consequent exudation, this low submucous celloid growth 
readily assimilates the effused plasma into similar substance, and so the 
enlargement continually goes on. The morbid condition which most 
resembles it is enlargement of the Peyerian patches, which we shall 
presently describe. Induration not unfrequently occurs as the result of 
inflammation, and depends, beyond doubt, on a fibroid development of 
the exudation. Rokitansky says: "In scrofulous subjects the tonsils 
are often affected, in addition to hypertrophy and habitual hypersemia, 
with a peculiar blennorrhoea, and the purulent secretion not unfre- 
quently becomes inspissated, so as to form tubercular cheesy plugs, or 
even chalky concretions. These, in their turn, keep up a perpetual 
state of irritation in the tonsils." Cancerous disease is very rare in 
this situation, but common indurated enlargement has often been spoken 
of as scirrhous. 



II. MORBID CONDITIONS OF THE TEETH. 

The brief summary that we shall give of these conditions is taken 
from the excellent work of Mr. Tomes on the subject, to which we must 
refer for fuller information. Malposition of the other teeth is scarce 
more than a disfigurement, but when the wisdom teeth take a wrong 
direction the effects produced are sometimes very mischievous. Those 
of the lower jaw cause more serious evil by their wanderings than those 
of the upper. Sometimes the tooth, though not deviating from its pro- 
per position, is held down by indurated gum. Esquirol mentions a case 
in which mental derangement depended on this cause. The wisdom 
tooth may take a false direction inward or outward, and cause by its pres- 
sure, ulceration of the tongue or the cheeks. It may grow directly 
forwards against the posterior surface of the second molar, which has 
proved the source of severe pain, resisting all treatment but that of ex- 
tracting the offending tooth. Lastly, the tooth may advance against 
the coronoid process, causing disease and necrosis of the bone, and in- 
flammation and abscess in the surrounding parts. The teeth are very 
liable to caries, which is an affection very much of the same kind as that 
occurring in bones. Mr. Tomes believes that " the dentine, from abnor- 
mal (nutritive) action, loses its vitality," and therewith becomes liable 
to be decomposed by the fluids of the mouth. It seems necessary that 
both conditions should exist, that the tissue should be dead, and that the 
oral fluids should be in an acid state, capable of dissolving it. Test 
paper applied to carious teeth almost invariably shows the presence of 
free acid. Healthy saliva is alkaline, while that of dyspeptic persons 
is prone to be acid, and it is in such that caries is most apt to occur. 
The enamel is, of course, first affected, but a very small perforation 
through this tissue may exist with a considerable amount of disease in 
the subjacent dentine. It appears that when the acid solvent has once 



456 MORBID CONDITIONS OF THE TEETH. 

penetrated to the surface of the dentine, it extends laterally under the 
enamel, destroying, extensively perhaps, the body of the tooth, and 
undermining and eroding the enamel on its attached surface. The de- 
structive process does not go on nearly so fast in the fang, which seems 
to possess a higher degree of vitality than the crown. A most interest- 
ing observation of Mr. Tomes demonstrates completely the vital nature 
of the actions going on in the dentine under the influence of disease. 
He shows that when a portion of dentine has become dead, it is circum- 
scribed by the consolidation of the adjacent living tissue. " The tubes 
become filled up, they are rendered solid, and the circulation is cut off 
from the dead mass by the obliteration of the tubes." It is remarkable 
"that the consolidation does not go on gradually from without inwards, 
keeping in advance of the decay, but occurs at intervals." It is formed 
also in successive lines, a second one being produced when the first be- 
gins to be attacked, and afterwards a third, when the second gives way. 
The consolidated zones vary in width and in completeness, probably 
according to the vigor of the conservative action. Another interesting 
exhibition of vital action is displayed in the production of secondary 
dentine by the surface of the pulp, under the excitement of caries in 
the contiguous tissue. This vascular papilla, originally the formative 
organ of the dentine, which had for years confined its action to nourish- 
ing the perfected structure, under the stimulus of disease renews its 
formative action, and throws out a barrier between itself and the ad- 
vancing mischief. How very analogous is this to the throwing out of 
lymph on the outer surface of a hollow viscus which is threatened with 
ulcerative perforation ! The structure of secondary dentine is not so 
perfect as the original, and it is commonly vascular. Under the micro- 
scope "a transverse section of carious dentine, rendered soft, like carti- 
lage, from the loss of its lime, presents a cribriform ap- 
Fig. 207. pearance. The tubuli are much enlarged and irregular 

in outline," differing entirely from their normal shape. 
This indicates that the solvent enters the tubes, and dis- 
solves, first, their walls, and afterwards the intertubular 
material. In the consolidated zones the deposit obliter- 
ating the tubes is first removed, and afterwards their 
walls and the intervening tissue. A confervoid growth is 
very often seen on carious teeth, and on the tartar that 
may incrust them. Imperfect formation of the enamel 
is a frequent cause of caries. It is mostly deficient on 
Drawing of a tooth ^ e sur f ace presenting deep pits, with the intervening; 

attacked by caries, n l i i <• i 11 

with barrier of se- structure well developed; sometimes, however, small 
condary dentine. cavities exist in its substance, while the rest is perfect. 
Deep narrow fissures are often met with extending from 
the free surface to within the T Jo tn °f an i ncn °f tne dentine; the 
enamel forming the walls of these is in parts perfect, in parts imperfect. 
Not only may the enamel be deficient, but it may be also imperfectly 
formed in various parts. The columns of its pulp consist of cells and 
granules, which, normally, become lost and fused in the homogeneous 
fibre; sometimes this fusion does not take place, and the granules re- 




MORBID CONDITION'S OF THE TEETH. 457 

main, giving the enamel fibre a permanently granular aspect; or the 
cells do not undergo their wonted arrangement and elongation, and thus, 
though they calcify, do not form fibres. Sometimes the fibres of the 
enamel are not perfectly united at their margins; the resulting inter- 
space may either appear as a broad line, or as a series of minute 
cells. 

The teeth are subject not only to decay, but to death, to necrosis, 
which may be either complete or partial. After this has occurred, cer- 
tain physical changes commence. " The tooth gradually assumes a 
darker hue than natural, which increases in intensity till it is almost 
black. The dental periosteum gradually detaches itself from the fang, 
the tooth becomes loose, and unless held in by the crooked form of the 
roots, drops out. The surface of the fangs is generally rough, and, 

Fig. 208. 




Imperfect formation of enamel. From Mr. Tomes's work. 

A. Enamel. 

B. Dentine. 

c. A perforation in the enamel. 

D. A cribriform layer of tissue in the enamel. 

e. A large cell lying transverse to the enamel-fibres. 

f. Cells in the enamel about the apices of the coronal dentine. 
G. Lines of minute cells between the enamel-fibres. 

near the neck, dotted over with nodules of hard green-colored tartar, 
while the ends of the roots often look worm-eaten, as though absorp- 
tion had commenced." Mr. Tomes compares the process of necrosis 
of a tooth with that which occasions the shedding of the antlers of 
a deer. In both, the minute tubes or cavities through which nutrient 
fluid is conveyed, become obliterated by calcareous deposition ; the whole 
tissue being consolidated into an inorganic mass. The dead tooth acts 
as a foreign body, causing inflammation and suppuration of the dental 
periosteum, as well as absorption of the latter, the alveolus, and gums. 
More serious effects are occasionally produced, " the periosteum of the 
alveoli becomes inflamed, together with the neighboring parts;" and, if 
the case be still neglected, the adjoining teeth are not unfrequently lost, 
and necrosis of a considerable part of the jaw may also result. In 
some instances, where the death of the tooth has taken place gradually, 
patches of newly-formed cementum, thrown out by the irritated dental 



-±58 MOKBID CONDITIONS OF THE TEETH. 

periosteum, adhere closely to the latter, and thus the tooth is held in 
its place. A single spot of necrosis in the fangs may cause inflamma- 
tion, and abscess, and such severe pain that the tooth, though otherwise 
quite healthy, is obliged to be removed. " Instances are not uncommon 
when the pulp of the tooth has died while the external surface of the 
fang has preserved its vitality. In these cases the dentine becomes dis- 
colored, and gives a general dark appearance to the tooth. One of the 
three fangs of a molar tooth may alone be affected by necrosis, or the 
disease may be confined to one side of a single fang, producing absorp- 
tion of the gum and alveolus on that side. 

The layer of osseous tissue, called cementum, which coats the fangs 
of the teeth, is liable to become hypertrophied. This may proceed to 
such an extent that the fang near its extremity may be twice the dia- 
meter of the neck. It results from irritation of the dental periosteum, 
which may itself be occasioned by caries, or necrosis of the tooth. The 
enlarged fang necessarily compresses and irritates the nerves which 
pass through the orifice at its extremity to the pulp ; and this irritation 
may be the cause of epileptic seizures, or paroxysms of neuralgic pain. 
The fangs of the teeth are occasionally absorbed to a greater or less 
extent, in some rare instances to the same extent that those of the tem- 
porary teeth are. The dental pulp, a highly sensitive and delicate 
structure, is very liable to be affected by severe pain from the irritation 
of caries in the tooth, or even from disease of the pulp of an adjacent 
tooth, or one situated on the opposite side or even in the other jaw. 
This is an excellent example of the reflection of sensations. Inflam- 
mation often attacks the dental pulp, changing its natural pinkish-gray 
color to a bright scarlet, and terminating very commonly in its suppura- 
tion and death. Sometimes when there exists an opening formed per- 
haps by caries, into the pulp cavity, the inflammation affects only a 
part of the pulp. This is intelligible from the circumstance that the 
secreted matter has a channel of exit, and does not diffuse itself over 
the rest of the pulp, and also because the irritation of the oral fluids, 
and of the carious dentine, is confined to the adjacent part of this struc- 
ture. The inflammation, after having caused the destruction of the 
pulp, may extend to the dental periosteum, and occasion the death of 
the fang; it may even extend further to the periosteum of the jaw, and 
produce necrosis of the bone. The dental pulp may be removed by 
absorption after the cavity of the tooth is laid open by caries, or it may 
ulcerate or perish from gangrene. Or again, it may become the seat of 
a fungoid growth, not of cancerous nature, which is sometimes termed 
polypus. 

The dental periosteum may be inflamed acutely or chronically. When 
the former takes place, it causes the periosteum to separate, to a greater 
or less extent, from the surface of the fang, leaving a cavity which is 
occupied by pus. The cavity becomes enlarged at the expense of the 
alveolus, and this chiefly at the apex of the latter. Sometimes the 
pus makes its way into the mouth at the neck of the tooth, having de- 
tached the periosteum up to that point ; but more commonly the abscess 
advances through an opening in the alveolus into the gum, from whence 
it ultimately makes its way to the surface. In unhealthy states of 




THE PHARYNX AND (ESOPHAGUS. 459 

system, the disease may involve the bone adjacent, and cause necrosis 
to a considerable extent ; or it may creep on and affect the 
periosteum of contiguous teeth. The inflammation rarely Fi g- 209 - 
arises spontaneously ; most often it is the sequel of inflam- 
mation of the pulp. In the chronic form, there is no tendency 
to the formation of abscess, but there may be a slight dis- 
charge of pus from the edge of the gum. " The tooth becomes 
loose, the alveolus absorbed, and the edge of the gum in- 
flamed. The gum gradually sinks with the absorption of 
the alveolus, and the tooth drops out or is removed." pumi^tcystat 
Sometimes partial chronic inflammation occurs, causing the fang of a de- 
"the periosteum about the extremity of the tooth to be- caved tooth, often 
come thickened and nodulated." The alveoli are liable to *^^ OI w n 

.... _ of most serious 

necrosis from various causes, as other bone is; they undergo mischief. 
absorption in old age naturally, and sometimes prematurely 
in persons who have been subjected to long-continued salivation, or 
whose gums have been rendered unnaturally vascular by other causes ; 
and, lastly, they are sometimes the seat of exostosis, which, gradually 
as it increases, extrudes the tooth. 



III.— ABNORMAL CONDITIONS OF THE PHARYNX AND 
OESOPHAGUS. 

This part of the alimentary canal may be congenitally absent, or may 
terminate in a coecal pouch, or be fused with the trachea, or be dilated 
into a sac, or, in rare instances, be traversed by separate fissures. The 
pharynx and oesophagus sometimes become dilated throughout, their 
parietes, and especially the muscular tunic, being hypertrophied. Roki- 
tansky alludes to one case in which the passage was large enough to 
admit a man's arm. In some instances, of a less degree of dilatation, 
the coats are relaxed and attenuated. Partial dilatation appears in the 
pouches which sometimes are formed by all the coats of the canal, 
sometimes consist of the mucous membrane only. In the latter case, 
"the mucous membrane is protruded between the muscular fibres, and 
becomes dilated by the food that enters; it is at last forced out in the 
shape of a cylindrical appendix, which lies between the vertebral column 
and the oesophagus, in a line with the axis of the pharynx, so that all 
ingesta pass into it, and death from starvation results." 

The oesophagus is liable to be constricted, either by the compression 
of external growths, or by cicatrices in its own walls, the results of 
former ulceration or sloughing, or by cancerous formations in its coats. 
Acute inflammation occasionally attacks the pharynx, or rather its mu- 
cous lining, chiefly by extension of the disease in cynanche tonsillaris, 
or simultaneously with the fauces in scarlat. anginos. Sometimes the 
affection, though then generally less acute, is independent, and con- 
stitutes cynanche pharyngea. Chronic pharyngitis is very common, 
especially in persons of an atonic habit, or who speak much from the 
throat. The mucous membrane appears slightly swollen, and of an 
even surface, colored by an uniform redness, and denuded to some ex- 



460 



THE PHARYNX AND (ESOPHAGUS. 



Fie. 210. 




tent of its investing epithelium. In many cases, the redness is more 
patchy, and seems to affect more the small veins and adjacent capillaries, 

and is of a darker tint. M. Chomel has de- 
scribed one form of this affection, in which 
the mucous follicles are specially the seat of 
morbid action. He says the arch of the 
palate is seen to be covered by small red 
points, which are more thickly disseminated 
on and near the uvula. These become more 
numerous and larger as the disease advances, 
till at length they run into each other, form- 
ing ridges and raised patches, between which 
only a small part of the mucous membrane 
retains its natural appearance. It occurs 
much more frequently in males than females, 
and chiefly between the fifth and seventeenth 
years. Croupy inflammation sometimes ex- 
tends to the pharynx and commencement of 
the oesophagus, and, on the continent at least, 
diphtheritic exudations are by no means in- 
frequent in this situation. They are essen- 
tially similar to those which form on the 
buccal mucous surface, which have been 
already described. The pustules of variola 
are occasionally met with in the pharynx, 
and those which are caused by large doses of 
tartar-emetic in the lower third of the oesopha- 
gus. The same part of this canal is liable to softening, which, usually 
associated with softening of the stomach, attacks especially the left side, 
which adjoins the left pleura, and occasions perforation and effusion of 
the contents of the stomach into this serous cavity. Fibrous tumors 
originating in the submucous or deeper-seated areolar tissues may grow 
inward, and, obtaining an investment of mucous membrane, hang down 
into the oesophagus in the form of a polypus. Sometimes they remain 
without thus protruding in the submucous tissue. Tuberculous deposit 
is very rarely found in the pharynx or oesophagus. Cancer is more 
frequent in the oesophagus than in the pharynx, in the proportion 
of thirteen to four ; in the former, it mostly affects the upper part, just 
below the larynx : in both parts, it almost always assumes the form of 
infiltrated scirrhus, from an ulcerated basis of which soft fungoid growths 
may afterwards sprout. In the pharynx, according to Dr. Walshe, it 
generally presents, at least in the early period, "a hard imperfectly cir- 
cumscribed mass," which may form a tumor visible externally. In the 
oesophagus it mostly constitutes an annular layer, constricting the canal 
for a variable distance, and often, by extending outward, producing 
adhesion of the diseased mass to the spinal column. We have observed 
one instance in which encephaloid cancer in this situation had proceeded 
to a considerable extent without producing any symptoms. In the oeso- 
phagus of a man who died with peritonitis, there was a thick mass of 
encephaloid, ulcerated on the surface surrounding the lower part of the 



Stricture of the oesophagus. 



ABNORMAL CONDITIONS OF THE PERITONEUM. 461 

canal, just above the cardiac orifice of the stomach, for an inch and a 
half. It had evidently originated in the submucous tissue, and grown 
inward, not contaminating the other coats. Higher up, there were 
several smaller submucous tumors. Rokitansky mentions the formation 
of ulcerated openings communicating with the trachea and the bronchi, 
or even with the aorta and the right pulmonary artery. 



IV. — ABNORMAL CONDITIONS OF THE PERITONEUM. 

Congenital deficiencies in the peritoneum will, of course, exist when 
any of the viscera which it invests are absent, or imperfect, or when the 
walls of the abdominal cavity are in a like state. It appears also that 
the various folds may of themselves be imperfectly developed, e. g. the 
omentum or mesentery may be unnaturally small or absent. On the 
other hand, these same folds may be of unusual dimensions, as when a 
mesentery of more than common length allows the intestines to float up 
to the surface of an abdomen distended by ascites. Certain pouches 
are also occasionally met with, chiefly, according to Rokitansky, in the 
hypogastric, iliac, and inguinal regions, which somewhat resemble com- 
mencing hernial sacs, and like them may inclose and incarcerate portions 
of the intestine. Most remarkable changes in the shape and size of the 
peritoneum are produced by the dropsical distensions which it undergoes, 
and the displacements to which it is subjected in various cases of large 
and inveterate hernia. The peritoneum is extremely liable to inflam- 
mation, which may be of various degrees of acuteness, or may be chronic 
ah initio. The former is extremely common, and results not only from 
all causes of irritation applied to it, but also originates spontaneously; 
or, as Rokitansky avers, in consequence of the rheumatic poison. The 
inflammation varies much in extent ; very often it is general, affecting 
the whole membrane, but often also it is partial, confining itself to a 
certain region. The simplest instance of partial peritonitis which we 
can take is, perhaps, that which occurs when an ulcer is making its way 
through the walls of the intestine, and threatening to perforate them. 
Opposite the threatened spot, a patch of injected vessels appears on the 
serous membrane, which pour out a fibrinous exudation forming a pro- 
tecting investment, or an adherent medium uniting it to adjacent parts. 
Inflammation, however, when set up at one part is very prone, as in all 
serous membranes, to propagate itself to the surrounding, and thus it 
very commonly happens that peritonitis, which commences in one locality 
over an inflamed or irritated organ, diffuses itself over the whole mem- 
brane till it becomes general. In the early period, injected vessels are 
very distinctly seen in the inflamed membrane, forming streaks or patches 
of redness. The injection, however, is seldom very strongly marked, 
which is, perhaps, due in part to the readiness with which exudation 
takes place. This is often seen as a delicate thin layer of fibrinous 
matter closely investing the inflamed surface ; sometimes it is so scanty 
that it is scarcely discernible, unless the surface is carefully scraped, or 
adjacent intestinal convolutions are separated from each other, when it 
appears as minute filaments stretching across the interspace. The exu- 



462 



ABNORMAL CONDITIONS OF THE PERITONEUM. 



dation sometimes collects in the furrows between convolutions of intes- 
tines pressed together, and is more manifest there than elsewhere. In 
instances of sthenic inflammation the exudations are often very abund- 
ant, and much puriform is mingled with the fibrinous matter. Serous 
fluid is also poured out often in considerable abundance, and is rendered 
turbid by flakes and molecules of fibrin and pus-corpuscles diffused 

Fig. 211. 




Portion of inflamed peritoneum, with numerous glomeruli between the fibres. 

throughout it. In peritonitis, attacking persons who are in an asthenic 
state the serous and puriform effusions generally predominate. Adhe- 
sions are very often found in the peritoneum, connecting the visceral 
and parietal layers together, and are sometimes of considerable length ; 
in many instances, no doubt, they are the result of partial inflammations 
giving rise to fibrinous exudation, which is afterwards transformed into 
areolar tissue; in other cases we are inclined to think the exudation 
takes place with little or no preceding hyperemia. The inflamed mem- 
brane becomes somewhat thickened by the effusion taking place in its 
own texture. In the specimen from which the annexed sketch was 
taken, numerous small corpuscles somewhat resembling glomeruli were 
seen everywhere among the natural fibres. Bands of adhesion some- 
times become the cause of fatal incarceration of the intestine, an open- 
ing being formed by these means into which a coil of intestines passes, 
and after a time having become distended, is strangulated by the ab- 
normal band. A case of this kind is recorded in the Report of the 
Pathological Society, 1851-52, in which seven or eight inches of the 
lowest part of the small intestine were strangulated by a ring formed 
by a strong fibrous band passing from the mesentery to the anterior 
surface of the rectum. The intestines are very commonly distended by 
gas in acute peritonitis, which is probably secreted by the mucous mem- 
brane under the influence of the irritation to which it is subjected in 
consequence of the adjoining inflammation. At the same time there is 
reason to believe that the action of the muscular fibres is more or less 
interfered with if they are not actually paralyzed, and hence the dis- 
tension being unopposed is greater than it otherwise would be. Roki- 
tansky says that " hemorrhagic exudation is frequently seen on the 
peritoneum; it forms large, saturated coagula, disposed in thick layers." 
Suppuration, as has been said, is not unfrequently a result of acute 
peritonitis, the purulent matter being, as it were, smeared all over the 
surface of the membrane ; sometimes, however, it takes place in a single 
part, and forms a circumscribed abscess. On opening the abdomen of 
a female who had been attacked with peritonitis after the operation of 
ovariotomy, and who survived several weeks after the inflammation had 



ABNORMAL CONDITIONS OF THE PERITONEUM. 463 

been subdued, there was found not only traces of lymph on the surface 
of the intestines, but a quantity of well-formed pus in the interior of a 
cavity formed by adjacent convolutions. Had life been prolonged, the 
pus would have made its way by ulceration into the intestinal tube, and 
thus been evacuated. Rokitansky, in mentioning this occurrence, speaks 
of the abscess sometimes discharging itself through the abdominal 
parietes, or opening this way as well as into the intestine, so that a 
fistulous communication with the bowel is the result. Chronie peri- 
tonitis of a simple kind is not of common occurrence ; a case is, how- 
ever, recorded by Andral,in which serum, turbid with albuminous flocculi, 
was found in the serous cavity after death, while ascitic effusion had 
existed for more than the last month of life, unattended with pain or 
any evident symptom of inflammatory action. We think we have seen 
a case somewhat similar. There is, however, another form of what may, 
perhaps, be termed chronic peritonitis, though we doubt very much its 
essential dependence on any inflammatory process. In this, the serous 
surface is invested closely for a greater or less extent by a firm, whitish, 
false membrane, which can be pretty easily detached from the subjacent 
peritoneum, and appears, when held up to the light, of much thinner 
texture in some spots than in others. The situation in which the false 
membrane is most completely formed is upon the surface of the liver, to 
which it forms sometimes a complete capsule, compressing and atrophy- 
ing it, and giving rise to ascites from interference with the 'free passage 
of the blood through the structure of the gland. We incline to the 
belief that these exudations, which we have seen on the surface of the 
pleura, as well as on that of the peritoneum, are the results of an ab- 
normal condition of the fibrinous constituent of the blood, in consequence 
of which it is prone to be effused either in the substance of tissues, as 
in cirrhosis, and puckering of the cardiac valves, &c, or on the surface, 
as in the case before us. One of the best-marked varieties of chronic 
peritonitis is that which is often justly called "tubercular," from its being 
essentially dependent on the presence of tubercles in the peritoneum. 
These appear sometimes as semi-transparent gray granulations, some- 
times are more opaque, though still of miliary dimensions. They are 
diffused everywhere throughout the subserous tissue, but are said by Dr. 
West to be most numerous on the surface of the diaphragm, or on the 
abdominal walls in the neighborhood of the spleen, while the parietal 
peritoneum is not so much affected as other parts. The chief 
tubercular deposit is sometimes in the omentum, and may assume 
the form of crude tubercular masses. Inflammatory irritation is pro- 
duced by the tubercles acting as foreign bodies ; exudation of lymph 
takes place, and adhesions are formed between adjacent parts of the 
serous surface, which are often so close and dense that the intestines or 
other viscera are torn in making an attempt to separate them from each 
other. We have seen the whole of the serous sac in this way entirely 
obliterated. There is usually some serum in the peritoneal cavity, but 
no puriform matter, unless, as occasionally happens, acute inflammation 
has supervened upon the chronic, and proved fatal. The tuberculous 
deposit sometimes undergoes softening, as in other situations, and the 
extension of this process may cause perforation of the walls of the in- 



464 ABNORMAL CONDITIONS OF THE PERITONEUM. 

testines, and either establish unnatural communications between distant 
parts which have become adherent together, or lead to the effusion of 
the intestinal contents in the serous cavity. The latter event, however, 
is more likely to be produced by the softening of tubercle in the sub- 
mucous tissue, w T hich is often present there at the same time as well as 
in the mesenteric glands. There is no relation apparently between the 
amount of deposit in the peritoneum, and in these two other localities. 
The lungs and bronchial glands are often tuberculous when the perito- 
neum is affected, but often in a much less degree, and they may some- 
times be exempt altogether. Rokitansky describes the muscular tunic 
of the intestines as being still more affected in this disease than in acute 
peritonitis ; it becomes pale, is easily lacerated and broken up. This 
gives a further reason why laceration often occurs on attempting to 
separate the intestines which are matted together. 

The peritoneum often appears somewhat thickened, of a dull, dense, 
whitish sodden aspect in cases of chronic ascites. We have examined 
the membrane thus altered, but w r ere unable to find any very marked 
alteration in texture, only that the tissue seemed more granular and 
less purely fibrous than natural. A local change of somewhat the same 
kind is often seen in the peritoneal covering of the liver and the spleen. 
In these it forms dense whity patches, which shade off gradually at 
their margins, and are for the most part quite free from bands of ad- 
hesion on the surface. The change in the splenic capsule is often so 
great that it has been termed "cartilaginification." When the exuda- 
tion, which in all these cases takes place into the subserous tissue, 
contracts and draws the part together, it produces "tabulated laminae, 
and projecting granulations," of a firm, dense structure. Calcareous 
matter is sometimes deposited in these fibrous formations, and gives rise 
to "compact, smooth, or uneven tabulated plates of varying thickness." 
It appears from Rokitansky's account, that false membranes, the result 
of inflammation, may be so disposed as to form serous cysts, which 
obtain an internal smooth lining, and are either pedunculated or sessile 
on the peritoneum. 

Cancer attacks the peritoneum in some very rare cases primarily, 
but most often by an adjoining growth extending to it, " perforating it, 
and penetrating into its cavity." The disease is sometimes of the 
encephaloid variety, but more often of the colloid. The latter, when 
the process of development is acute, is often spread over the entire 
serous surface, in the form of small, miliary nodules, in some parts 
clustered together. "Sometimes it occurs as a layer of areolar cancer- 
ous tissue, varying in thickness, or as a circumscribed, round, tabulated 
aggregation. The omentum is very commonly found to shrivel up and 
to degenerate into a transverse band ; or, in the opposite case, with an 
enormous increase of size into areolar cancer." Cancerous growths not 
uncommonly originate in the post-peritoneal cellular tissue just in front 
of the spine. In this part they are firmly adherent to the vertebras ; 
are of homogeneous ( probably firm scirrhous) texture, and confounded 
with the crura of the diaphragm. In its peripheral parts the growth 
has a more loose and tabulated structure. Dr. Walshe, tracing the 
progress of the mass from its point of origin, says, "it spreads upwards, 



ABNORMAL CONDITIONS OF THE STOMACH. 465 

extends to the stomach, presses under the liver, penetrates between 
the laminae of the transverse mesocolon, twists round the duodenum and 
pancreas, and, pushing forward the stomach (with the small curvature 
of which it contracts adhesion), forms a tumor in the epigastrium. 
Such tumors mould themselves upon these various parts and organs in 
so close a manner, that, after separation, the surface of the mass retains 
the impressions of the adjoining viscera." The course of these growths, 
though rapid, is often for a long period unattended with pain or dis- 
turbance of the system. 



V.— ABNORMAL CONDITIONS OF THE STOMACH. 

In very imperfect monstrosities, especially the acephalous, the stomach 
is either wanting, or very imperfectly developed. It i3 also absent 
occasionally, according to Rokitansky, in individuals otherwise normally 
built, and provided with a well-developed intestinal tube, or it may be 
only indicated by a small saccular dilatation of the oesophagus. The 
shape of the stomach is sometimes found remarkably altered; its cavity 
being partially divided into a cardiac and pyloric portion by an annular 
contraction, or even still further subdivided into three or four sacculi, 
so as to present some resemblance to the multiple stomachs of ruminants. 
These peculiarities of shape may either result from congenital malform- 
ation, or at least, in their minor degrees, from irregular contractions of 
the muscular coat, or from destruction of substance and subsequent 
cicatrization. Sometimes the stomach deviates from its usual shape, in 
the way of assuming greater simplicity; it is destitute of its cardiac 
cul-de-sac, and the oesophageal opening is quite at its left extremity. 
The stomach is liable to great variations of size; these within certain 
limits are physiological, and are manifestly contemplated in the peculiar 
convoluted disposition of its mucous lining. A healthy stomach, when 
empty, naturally contracts upon itself, and this to such an extent that 
its cavity is wellnigh obliterated. This is purely the effect of the un- 
opposed action of its muscular coat, and is no evidence of disease in the 
viscus. It may proceed from starvation, or from stricture of the oeso- 
phagus. Contraction of the cavity of the stomach in a less degree may 
be produced by hypertrophy, and cancerous disease of the coats, or by 
the cicatrization of extensive ulcers. Dilatation of the stomach, often 
to a considerable extent, is of very common occurrence, and depends, 
partly, on copious secretion of gas from its lining membrane, and partly 
on loss of contractile power in its muscular fibres. In its more extreme 
degrees, it is generally the result of obstructive disease at the pyloric 
outlet, in consequence of which the ingesta accumulate within the 
cavity. The distension in such cases is sometimes so enormous that 
the stomach extends over the entire abdominal cavity. Rokitansky 
says, "that repeated repletion, in consequence of a morbid appetite," 
may become the cause of as great distension as when the pylorus is 
obstructed ; or that this may also " occur as a result of paralysis from 
concussion, traction, or dislocation, produced by large scrotal hernias, 
and that it kills slowly with vomiting, with or without gangrene of the 
30 



466 ABNORMAL CONDITIONS OF THE STOMACH. 

mucous membrane, under symptoms of complete paralysis." The coats 
of the stomach may be abnormally thick, either in consequence of can- 
cerous disease, or from simple hypertrophy of the muscular layer. The 
pyloric outlet is generally the part where muscular hypertrophy shows 
itself, and here it seems to affect more especially the layer of annular 
fibres. Atrophy of the coats, speaking generally, is most commonly 
observed in cases attended with much emaciation ; it occurs also some- 
times in consequence of extreme dilatation of the cavity, sometimes 
spontaneously. The muscular layer is, in most cases, the one most pal- 
pably affected; the mucous membrane is, however, not uncommonly 
atrophied also, as we shall more particularly describe when speaking of 
textural changes. The following list of abnormal situations, which the 
stomach may occupy, is given by Kokitansky : " It may lie external to 
the abdominal cavity in eventration, and in umbilical hernia ; in the 
left side of the thorax, the diaphragm being wholly or partially absent 
on that side ;" it may lie vertically, as in the foetal state ; or with the 
fundus on the right ride, as in general lateral transposition. The fore- 
going are congenital malpositions ; the following acquired. The sto- 
mach may protrude externally after extensive wounds, or make its way 
into the thorax, after injuries to, or ruptures of, the diaphragm; it may 
be carried down into large hernial sacs, especially umbilical and scrotal ; 
or be displaced by new growths or enlargement of adjacent organs ; or 
sink lower itself, in consequence of increase in size, as in the case of a 
scirrhous pylorus. 

Acute inflammation of the stomach but rarely, if ever, occurs, except 
as the result of irritants directly applied to it. The cases related by 
Andral give proof, however, of its existence as an idiopathic affection, 
or as the sequel of rheumatism, or of epidemic cholera. We quote the 
account he gives of the morbid changes. In Case 1, the stomach was, 
strongly contracted so as to be nearly the size of the transverse colon : 
" Its inner surface, over nearly its entire extent, was of a brownish red. 
This color had its exclusive seat in the mucous membrane, which had 
become in every part very thick, and was at the same time very friable. 
On its free surface there was discovered a multitude of small red or 
blackish points, which seemed to have their principal seat in the villi ; 
however, beneath these the body of the mucous membrane was red, and, 
as it were, penetrated with blood ; in no part could this membrane be de- 
tached, it gave way under the forceps, and in several points it resembled 
a pulp without any consistence." Near the pylorus, the mucous mem- 
brane resumed its normal consistence, and was of a grayish color. In 
Case 2, also, the stomach was strongly contracted. Its mucous mem- 
brane was of a dark red color, over the entire surface of the great cul- 
de-sac, and over all the posterior surface from the cardia to the pylorus. 
This redness penetrated the entire substance of the membrane, which 
had lost its consistence in every part where it was red; in some points 
it was merely a sort of pulp. Towards the anterior surface the mucous 
membrane presented a slate-colored tint, without its consistence being 
much changed; near the pylorus some mammillation was observed. 
The surface was covered by a viscid thready mucus. In another case, 
also idiopathic, the parietes of the stomach were remarkably softened, 



ABNORMAL CONDITIONS OF THE STOMACH. 467 

" over all the left portion of this viscus, its tunics, from the peritoneal 
to the mucous, had no longer any consistence ; they gave way under the 
fingers as a sort of pulp. Wherever this softening existed, the parietes 
of the stomach were of a dark red color, and as it were ecchymosed. 
Near the pylorus the parietes of the stomach resumed their natural con- 
sistence," and of a grayish tint. In persons dying of gastritis, conse- 
cutive to a malignant cholera, Andral found, at an early period of the 
disease, the mucous membrane red and softened; at a later period it was 
sometimes in the same condition, sometimes brown or slate-colored, and 
its tissue thickened and indurated. Judging from our examinations of 
other inflamed mucous membranes, we feel no doubt that the microscope 
would show, in such instances, more or less hyperemia of the vessels, 
with abundant granular exudation, stained by exuded hsematin in the 
substance of the mucous tissue, as well as loss of its investing epithe- 
lium, and wasting or breaking up of its glandular tubuli. We feel the 
more confidence in Andral's description above quoted, because he has 
so carefully distinguished inflammatory hyperemia from mere passive 
or post-mortem congestion, or red staining, and has contended so pru- 
dently against the extravagances of over-zealous Broussaians. We have 
recently examined an excellent instance of intense hyperemia of the 
stomach. The whole mucous surface was of a deep red, almost black; 
the subjacent tissues were much less affected. The cavity was empty, 
and the organ was much contracted. The surface was uncovered by 
mucus, only a little alkaline fluid lay in the furrows between the rugae. 
The capillaries were gorged with blood in every part of the membrane, 
they were seen running parallel to the tubes in their whole length, but 
those which adjoined the free surface (which are always the most con- 
gested), had given way in numerous spots, and saturated the tissue round 
them with extravasated blood. The tubes were healthy, and there was 
no apparent exudation among them. The patient died with cardiac 
hypertrophy and general dropsy. The liver and spleen were much con- 
gested, and it is pretty certain that the hypersemia of the stomach was 
passive rather than active. 

As Rokitansky observes, we have rarely, if ever, the opportunity of 
observing the first stage of acute catarrhal inflammation of the stomach, 
but we may reasonably infer that it consists, as in other parts, of a more 
or less considerable hyperemia, which relieves itself by a copious exu- 
dation of mucus upon the surface, instead of a fibrinous exudation in the 
substance of the tissue. A chronic catarrhal state is by no means un- 
commonly met with, the anatomical characters of which Rokitansky 
enumerates " as a dark reddish-brown, or slate-gray, or even blackish- 
blue discoloration of the mucous membrane, copious secretion of a stone- 
colored, occasionally glassy pituita, thickening, increased condensation 
and induration, i. e. hypertrophy of the mucous membrane, which pre- 
sents itself in various degrees : (a.) In the lowest degree, the mucous 
membrane shows simply an increase of thickness and hardness in its 
tissue ; (/3.) In a higher degree it presents, in addition to its increased 
thickness, an uneven, racemose, or warty surface, a surface mamellone'e; 
(y.) In a still more advanced degree, it forms prolongations in the shape 
of permanent firm folds or of polypus. The submucous cellular tissue, 



468 ABNORMAL CONDITIONS OF THE STOMACH. 

and the muscular coat, also participate in this hypertrophy in various 
degrees — the entire parietes of the stomach presenting unusual thick- 
ness, firmness, and hardness. The pyloric portion is the chief seat of 
chronic catarrh, and it is there that hypertrophy of the mucous and 
other membranes is most prominent." Andral remarks that, in chronic 
gastritis, the mucous membrane may appear after death to be in a per- 
fectly natural state, or at least to have undergone no alteration discerni- 
ble by the eye. The subjacent tissues, and particularly the submucous 
areolar tissue, are, however, in these cases more or less affected. In 
the majority of instances, however, the color, the consistence, and the 
substance of the membrane are variously changed. A gray slate, brown, 
and more or less deep black tint are often observed, as well as some- 
times a dull white milky aspect. In regard of consistence, the mucous 
membrane may be indurated, or softened ; the latter is more frequent 
than the former. Induration may exist with all the different shades of 
color just mentioned. With respect to its substance the mucous mem- 
brane may be thickened or attenuated, or may remain unaltered. A 

Fig. 212. 




Vertical section of mucous membrane of stomach, the tubes being completely wasted and replaced by fibroid 
tissue, (a.) Eemains of mucous membrane. (6.) Fibroid tissue, (c.) Fat-cells. 

state of thickening may coexist with induration or with softening; the 
former combination is peculiar to chronic gastritis, and affords a good 
example of false hypertrophy. Induration, like the thickening, may be 
partial or general. Attenuation of the gastric mucous membrane is 
most often met with towards the great cul-de-sac, in the same situation 
where softening is most frequent. Andral says : "Sometimes, however, 
I have found the mucous membrane towards the pylorus, so attenuated 
that it resembled a sort of transparent extremely fine web. On attempt- 
ing to raise it, it was changed into a reddish-white pulp, as happens in 
certain degrees of softening." He admits, what we shall presently 
remark, that this attenuation may occur as a pure atrophy totally inde- 
pendent of inflammation. 

We have lately examined carefully with the microscope more than a 
hundred stomachs taken indifferently, and have published, in the Assoc, 
Journal for Oct. 7th and Jan. 27th, 1854, the details of the following 
varieties of change : (1.) One of the commonest, especially in its minor 
degrees, consists in the infiltration of a low fibroid tissue loaded with 



ABNORMAL CONDITIONS OF THE STOMACH. 



469 



nuclei among the tubes, which themselves undergo atrophy, so that at 
last the mucous membrane totally loses its tubular aspect, and becomes 
a mere fibroid stratum, more or less densely set with nuclei throughout. 
In this state the basement-membrane may still persist, and the thick- 
Fig. 213. 




Vertical section of mucous membrane of stomach, showing the lower parts of the tubes, and a nuclear 
mass extending among them upwards, (a.) Tubes, (b.) Nuclear mass, (c.) Submucous tissue. 

ness of the tissue be little diminished. In some instances the nuclei 
disappear, and the fibroid stratum develops fibres more decidedly. (2.) 
There are formed masses of nuclear particles, most often at the bases of 

Fig. 214. 




Cavity formed in the mucous membrane of stomach, by the disintegration of a nuclear mass. The sur- 
rounding tissue is pervaded by nuclear deposit, (a.) Basement-membrane of surface. (6.) Altered m ucous 
membrane, (c.) Submucous tissue. 



the tubes encroaching upon them, often also in the substance of the 
mucous membrane, and sometimes at its surface : these are sometimes 
circumscribed, sometimes diffused, and then pass into the preceding 
forms by gradual shades. (3.) The nuclear deposits sometimes seem 
to give rise to cystic cavities, or these may form from dilatations of the 
tubes, or arise de novo, as in other situations. (4.) The mammillated 
condition appears to depend on a process of local atrophy, at least in 
most cases, the tubes being wasted in the track of the furrows, which 



470 ABNORMAL CONDITIONS OF THE STOMACH. 

sometimes are so deep as to fissure the membrane down to its corium. 
(5.) A fatty state is very commonly met with, and in two forms, one 
in which the epithelium is bulky and the tissue healthy, or nearly so ; 
the other, where the epithelium is atrophied, in consequence, generally, 
of pressure by new-formed fibroid tissue upon the tubes. (6.) The 
tubes in the pyloric region are often found changed in the following 
manner : the continuous row of tubes is interrupted, and there are seen 
at intervals instead groups of convolutions containing a fatty wasted 
epithelium, and not possessing any manifest outlet on the surface. We 
think that inflammation is not the most essential moment in these 
changes. The nuclear masses, when not of large size, may be regarded 
as identical with the naturally existing solitary glands. 

Croupy inflammation resulting in fibrinous exudation, which forms a 
false membrane, sometimes of regular areolar surface, is very rarely 
seen at least in England, and is said by Rokitansky to be a " sequela 
or degeneration of exanthematic processes, as of variola, typhus, pysemia, 
and particularly puerperal phlebitis. Sometimes inflammation of a low 
erysipelatous kind attacks the submucous cellular tissue of the stomach, 
and occasions suppuration. The pus, after a time, escapes by numerous 
irregular cribriform openings into the cavity of the viscus. 

We proceed to notice the effects of caustic fluids, such as the mineral 
acids, which have been swallowed. The mucus in the mouth and fauces 
is coagulated into flocculent masses, the epithelium is detached here and 
there, and "converted into a thick grayish- white, rugose layer," and 
the subjacent mucous membrane is pale. If the caustic fluid has pene- 
trated more deeply, "the superficial layers of the mucous membrane of 
the fauces and oesophagus are found congested, of a dirty, whitish, 
leaden hue, and the capillary network blackened by its carbonized con- 
tents. The lower strata of the mucous membrane, and the submucous 
cellular tissue, present serous infiltration. In the follicles at the root 
of the tongue, the mucous secretion is coagulated into dirty white 
masses. In a still higher degree of corrosive action, the entire mucous 
membrane is destroyed, and converted into a dirty gray mass, which is 
traversed by black vessels; the submucous cellular tissue is infiltrated, 
and partially ecchymosed; the muscular coat of the oesophagus itself is 
shrivelled, pale, ashy. In the highest degree, the mucous membrane of 
the oesophagus, together with the submucous cellular tissue, is converted 
into a soft, black mass, which is distended by a sanguinolent fluid, and 
is easily detached from the muscular coat. The latter is itself either 
destroyed in the same manner, or is perfectly colorless, friable, and 
presents an ashy, gelatinous appearance. The mucous membrane of 
the stomach," in consequence of being longer in contact with the corro- 
sive substance, "almost invariably suffers the changes of the last degree 
but one, though in varying extent and thickness. It is either affected 
in single folds, or streaks which pass from the cardiac orifice to the 
lesser curvature, and from the large curvature to the pylorus ; or over 
a large extent; or we find the entire surface converted into a black car- 
bonaceous mass, of several lines in thickness, distended by sanguinolent 
fluid, and consequently presenting a tumefied appearance." The muscu- 
lar coat is affected, and the parietes of the stomach are often perforated. 



ABNOKMAL CONDITIONS OF THE STOMACH. 471 

11 The acid affects the neighboring organs through the membranes, and 
thus either coagulates or tans the contained fluids, fuses the tissues into 
a gelatinous mass, or carbonifies them; the discoloration produced is 
always very marked. In many cases, not only the blood of the neigh- 
boring bloodvessels, but also of the larger trunks, and even of the aorta, 
is changed into pultaceous, pitchy, greasy, black cylinders. Beyond 
the stomach, and especially in the duodenum, and at the commencement 
of the jejunum, the effect of the lowest degree is exhibited in coagula- 
tion of the intestinal mucus, and of the chyle, in corrugation and opa- 
city of the epithelium, in the tanned state of the mucous membrane, 
and the dark injection of its vessels." The highest degrees of corrosive 
action are rapidly fatal, " the lowest degrees are followed by exudative 
inflammation, the mortified epithelium sloughs, and being replaced by a 
new formation, as soon as the reaction has abated, recovery ensues." 
In all the higher degrees, inflammation, passing into suppuration, pro- 
duces the separation of the superficial mortified layers. The suppurat- 
ing process may be protracted, or may terminate early with the forma- 
tion of cicatrices. " According to the depth to which the tissues are 
destroyed, the loss of substance is repaired under a formation of struc- 
tures that vary in size and consistency." When the mortification is 
limited by the submucous cellular tissue the latter becomes condensed, 
and " forms, at some places, projecting ridges, or valvular, and even 
annular, duplications towards the oesophagus;" in this way peculiar 
membranous strictures are produced. " If the muscular coat itself is 
involved, it is partially or entirely destroyed, and the walls of the oeso- 
phagus are converted into a fibro-cellular firm tissue, which contracts, 
and thus produces the most important and most resisting strictures." 
Chronic suppuration sometimes occurs as the result of profound injury, 
leading to the formation of abscesses and sinuses of the muscular coat, 
and of the surrounding cellular sheath of the oesophagus. These may 
produce perforation of adjoining passages, the trachea or bronchi, or 
may heal, leaving considerable contractions of the tissues and strictures. 
Cicatrices and strictures are formed in the same way, though less fre- 
quently, in the membranes of the stomach. The morbid changes pro- 
duced by arsenic are as follows: "At one or more points to which the 
powder happens to attach itself to a larger amount, the mucous mem- 
brane appears plicated and tumefied, reddened, invested by a detached 
epithelium, and a tawny exudation; its tissue is softened, pultaceous; 
and at the spot where the white grains of arsenic are attached, it is 
converted into a yellowish or greenish-brown slough." The tissue in- 
tervening between these solitary foci is often quite healthy. 

Ulceration of the coats of the stomach is much less frequent than 
that of other portions of the intestinal canal. It occurs sometimes as 
the result of chronic gastritis, or of the corrosive action of poisons. 
These ulcers require no particular notice ; but there is one particular 
kind which is rather peculiar to this organ, and which is of especial in- 
terest, from its occurring in tissues which otherwise appear quite healthy, 
and from the serious and rapidly fatal effects to which it too often gives 
rise. Rokitansky terms this the perforating gastric ulcer, on account 
of its having a decidedly marked tendency to perforate the parietes of 



472 ABNORMAL CONDITIONS OF THE STOMACH. 

the stomach. He describes it as follows: " In a well-defined case there 
is, in the region of the pylorus, a circular orifice of from three to six 
lines in diameter, with a sharp peritoneal edge, as if a round piece of 
the gastric parietes had been punched out. When viewed from within, 
the loss of substance on the internal membranes of the stomach, and 

Fig. 215. 




Perforating ulcer of stomach ; the mucous membrane is puckered into folds round it. 

especially of the mucous layer, appears more considerable, so that the 
edges of the hole seem bevelled off from within outwards." In some 
cases the margins of the ulcer are quite smooth and thin, in others 
thickened and indurated. " The pyloric half of the stomach," Roki- 
tansky proceeds, "is the seat of the ulcer: it is most frequently found 
in the middle zone of this portion ; it is oftener seen at the posterior 
than at the anterior surface, almost always near to, and frequently at, 
the lesser curvature; and it occurs in extremely rare cases only at the 
fundus." A similar ulcer may form in the upper oblique portion of the 
duodenum, but not, as far as observation has yet shown, in any other 
part of the intestinal canal. The size of these ulcers, Rokitansky tes- 
tifies, may equal that of a cheese-plate ; we have never seen them ex- 
ceeding that of a half-crown. Their form is commonly circular, at least 
in the outset, though they often become elliptical or quite irregular, a3 
they extend. Sometimes the ulcer enlarges in its transverse diameters, 
so as to obtain a zonular form. Sometimes two ulcers coalesce together 
more or less completely. " In the majority of cases there is only a 
single ulcer," (there is no mention of more than a single one in three 
cases which are recorded consecutively in the Report of the Pathologi- 
cal Society for 1847-48,) "but frequently there are two or three, occa- 
sionally four or five, and these are then commonly placed above or near 
to one another at the posterior surface of the stomach, or at the lesser 
curvature." When the ulcer is perfectly circular, the narrowing of its 
area, as it extends in depth, is very marked, the muscular coat is less 
extensively destroyed than the mucous, and the peritoneum again less 
extensively than the muscular ; the perforation, in fact, taking place, as 
Rokitansky describes it, in the centre of the included circle. The 
exact nature of the process by which the ulceration commences, is not 
at all ascertained, at least, has not yet been the subject of direct obser- 



ABNORMAL CONDITIONS OF THE STOMACH. 473 

vation. Rokitansky writes : " It is probable that it commences with an 
acute, circumscribed, red softening (hemorrhagic erosion) ; or with a 
circumscribed sloughing of the mucous membrane; it is still more pro- 
bable that the ulcer increases in this manner, the tissues at the base of 
the ulcer sloughing and exfoliating, layer by layer." He thinks that 
"the process offers a valuable analogy to sloughing of the lungs." We 
think the gastric ulcer may be very properly compared to the simple 
ulceration of the cornea, which it resembles closely in several respects. 
Both, when the system has made no reparative effort, may have smooth 
level margins. Both may heal by the deposition of fibrin at their base 
and around their margins. Both show, when they advance unchecked, 
a decided tendency to perforate the tissue in which they exist. In both 
the ulceration is evidently not the result of violent inflammation, but of 
a local loss of substance or disintegration. It seems as if the tissue 
slowly liquefied, molecule by molecule, in a given part, in consequence 
of defect of assimilative power. The process in the case of the cornea 
is evidently not identical with sloughing, such as occurs in purulent 
ophthalmia, and there is reason to believe that the same is true also of 
the analogous change in the gastric parietes. Rokitansky states that 
the ulceration " is invariably accompanied by chronic catarrh and blen- 
norrhea of the gastric mucous membrane." This we much doubt, for, 
though pain and various dyspeptic symptoms are complained of in most 
cases where ulcers of this kind are found, yet this is not constant, and 
certainly the amount of the dyspepsia is no indication whatever of the 
existence of ulceration. The point we wish especially to notice is, that 
the ulcerative action is not in any way dependent on irritation or in- 
flammation, but on a loss of vital assimilative power in the part affected. 
The bearing of this part upon the treatment is most important. Dr. 
Copland states, and some of our own observations are confirmatory, 
" that this affection is most frequent in needlewomen, or female ser- 
vants. The patients, in most instances, have been ansemic, or suffering 
from disordered menstruation, as well as from pains in the stomach, but 
" have generally been able to pursue their avocations, and to take their 
food, up even to the period of the fatal seizure." The ulcer, especially 
when seated near the smaller curvature, is apt to involve some arterial 
branch, from which blood is poured out in abundance. The hemorrhage 
may be so copious as to destroy life at once, but more frequently death 
does not occur till after repeated attacks. The deeper the ulcer has 
extended, the larger in general are the vessels it meets with, and the 
more serious, in consequence, the loss of blood. It has happened, that 
an ulcer, after perforating the coats of the stomach, has lighted upon 
the pancreatic duct, and produced a fistulous opening into it. The 
most dangerous situation for an ulcer to occupy is the lower half or two- 
thirds of the anterior surface of the stomach, as, in case of perforation, 
there is no organ to which it can easily become adherent. On the pos- 
terior surface, adhesions form between the stomach and pancreas, or the 
adjoining lymphatic glands, and on the upper and pyloric part of the 
anterior surface the escape of the gastric contents into the peritoneal 
cavity is sometimes prevented by the left lobe of the liver. In a re- 
markable case, recorded in the Report of the Pathological Society, 



474 ABNORMAL CONDITIONS OF THE STOMACH. 

1847-48, p. 252, the barrier opposed to the extension of an ulcer by 
the left lobe of the liver proved insufficient, as the destructive process 
continued until it perforated the diaphragm, and gave rise to hepatiza- 
tion and a gangrenous cavity in the lower lobe of the left lung. These 
ulcers may heal at any period of their course; it is not uncommon to 
find the cicatrices, which are their results, on the inner surface of the 
stomach. There can be no doubt that an effusion of plasma undergoing 
development into fibroid tissue, is the means whereby the separation is 
effected. This takes place both in the margins of the ulcer, producing 
thickening and subsequent contraction, and also at the base, which it 
lines with a thin smooth layer. Cicatrices of this kind present a de- 
pression of the size of the ulcer, surrounded by thickened and elevated 
margins, others, where more contraction has taken place, are of a linear 
or corded shape.. 

Hemorrhagic erosion of the gastric mucous membrane is thus described 
by Rokitansky: "There are round or roundish spots of the size of a 
pin's head or pea, or narrow elongated streaks, at which the mucous 
membrane appears dark red, lax, soft, bleeding, and presenting a de- 
pression in consequence of loss of substance or slight erosion. Sometimes 
this loss of substance involves the entire thickness of the mucous mem- 
brane and the submucous cellular tissue, and produces an appearance of 
small round, or striated ulcers. This process is invariably accompanied 
by hemorrhage," the effused blood being mixed in a more or less altered 
state with gastric mucus, which is poured out by the membrane affected 
with recent or inveterate catarrhal inflammation. The erosions are often 
very numerous, studding, perhaps, every part of the stomach, with the 
exception of the fundus ; their chief seat is at the pyloric portion. They 
are not peculiar to any form of disease. Microscopic examination of 
one of these ulcers showed the surface sunk in, the basement-membrane 
gone, and the tubes quite atrophied and replaced by low fibroid substance, 
infiltrated with diffused yellow pigment. 

Softening of the stomach requires an especial notice, as an affection 
of great importance, though as yet very imperfectly understood. One 
form of it, called by Cruveilhier gelatiniform softening, occurs, especially 
in infants, between the age of four and eighteen months. The process 
commences with the mucous membrane of the fundus, and " extends to 
the muscular coat and the peritoneum, converting them and the inter- 
vening cellular tissue into a grayish or grayish-red, transparent jelly, 
with a yellowish tinge, through which single dark-brown streaks, the 
broken-down bloodvessels, are observed to pass. The softened portion 
of the stomach tears at the slightest touch," and rents in it take place, 
sometimes perhaps during life, but more frequently after death. The 
softening process sometimes extends to the diaphragm, causing perfora- 
tion of it, and effusion of the gastric contents into the left pleura. Dr. 
Copland expresses his opinion, that "the softening often exists to a 
considerable degree previously to death; but the advanced stage of 
disorganization, and more especially erosion and perforation are early 
consequences of dissolution, which the fluid of the stomach may have 
been, more or less, concerned in producing." The same authority states 
that the disease is almost endemic in certain places, and epidemic in 



ABNORMAL CONDITIONS OF THE STOMACH. 475 

some seasons. " It may appear in the course of infantile remittent 
fevers, of hydrocephalus, or of chronic bronchitis ; or it may follow the 
cholera infantum, or scarlet fever, or diarrhoea, especially after weaning, 
or when the infant has not enjoyed the advantage of a healthy nurse, or 
is brought up by hand." " General ansemia," as Rokitansky testifies, 
"which is particularly apparent throughout the intestinal canal, and 
general collapse and wasting, which are chiefly evident in the muscular 
tissue, are constant accompaniments of this disease." It has been much 
debated whether the affection should be regarded as of an inflammatory 
nature: but the* entire absence of hypersemia, or of the products of in- 
flammation in the softened tissue, must be considered as almost decisive 
of the question. Rokitansky observing its frequent supervention on 
hydrocephalus, or some cerebral affection, suggests that " the proximate 
cause may be looked for in diseased innervation of the stomach, owing 
to a morbid condition of the vagus, and to extreme acidification of the 
gastric juice." The gastric mucous membrane is not unfrequently found 
softened in adults who have died from various diseases. Andral notices 
its occurrence in many chronic diseases, especially pulmonary ; and also 
as the first sign of failing power in old persons, whose health has been 
generally good. The morbid change betrays itself by anorexia, uneasi- 
ness and weight at the epigastrium ; emaciation and rapid loss of strength. 
Death takes place in the way of asthenia, without prominent affection of 
any organ, and the autopsy only reveals gastric softening, with or without 
hyperaemic injection. The color of the softened tissue, according to 
Andral (and we are quite disposed to agree with him), is by no means 
uniform ; it may be normal or paler than natural, or of a dead white, or 
red or brown. Rokitansky, on the other hand, says " the parietes of 
the stomach are converted into a more or less saturated dark brown or 
reddish pulp." In our examinations, we have very commonly, indeed, 
found the splenic region of the stomach more or less softened. The 
mucous membrane appears thinned, more translucent than usual, and 
dark stained ; under the microscope, its tubes appear in various degrees 
of disintegration. The change is, we think, partly post mortem, partly 
owing to failing nutrition ; its constant seat in the splenic region seems 
to be connected with the greater thinness of the walls, especially the 
muscular, in that part, in consequence of which it is very often abnormally 
distended. In some cases the other coats are involved, as well as the 
mucous membrane, and even the diaphragm may be thus perforated. 
" The stomach is found to contain large quantities of a fluid resembling 
coffee-grounds or ink, which is often vomited during life." The oeso- 
phagus, as we have before mentioned, is sometimes contemporaneously 
affected in its lower third, in consequence of which, perforations and 
effusion into the left side of the thorax may result. " The fundus is the 
seat of all the softening processes of the stomach," from whence they 
extend to the larger curvature. This applies not only to the softenings 
which commence during life, but, at least in the majority of cases, to that 
which occurs only after death. It is often difficult, as Rokitansky 
allows, to distinguish certainly between the mere cadaveric chemical 
changes, and those which take place from alterations in the vital nutri- 
tive processes. The distinction, however, may generally be made by 



476 ABNORMAL CONDITIONS OF THE STOMACH. 

attending to the following circumstances, which he enumerates : (a) " the 
absence of all symptoms during life which indicated softening, or the 
morbid processes that give rise to it ; (b) sudden death, from natural or 
other causes, during the digestive act, while the stomach is filled with 
chyme, without previous illness ; (c) limitation of the softening to the 
mucous membranes, and especially to the projecting folds, so as to form 
streaks; (d) and at the same time, its extension beyond the ordinary 
boundaries of morbid softening — its development being most remarkable 
at those points at which there is a stagnation of the greatest quantity 
of the gastric contents;" this latter circumstance determines the seat of 
post-mortem softening to be the part which is most depending. An 
experiment performed by M. Cameron, illustrates very well the influence 
of impaired vitality in promoting the softening of the gastric tissues. 
A fluid obtained from the stomachs of two children, who died from 
gelatiniform softening, was introduced into the stomach of a living rabbit, 
and produced no injurious effect; the viscus being found quite healthy 
when the animal was killed. Another rabbit was treated in the same 
way, having previously had its pneumogastric nerves divided, the mucous 
membrane of the stomach was found in a state of softening. If the 
nerves only were divided, no softening took place. This experiment 
seems confirmative of the opinion of Dr. Copland, noticed above. 

Fatty tumors, originating in the submucous tissue, and increasing in 
size, may either press inwards towards the cavity of the stomach, or 
outwards, towards the peritoneal sac. In either situation they may be 
sessile or pedunculated. Fibroid nodules sometimes form in the areolar 
submucous tissue, " chiefly in the vicinity of the cardiac orifice, and the 
lesser curvature." Erectile tissue may be developed at the free ex- 
tremity of polypoid growths, or may occupy a larger surface of a sessile 
tumor. Tubercle is very rarely seen in the stomach, and only occurs 
in cases " where intestinal tuberculosis has advanced to an extreme 
degree." Cancerous disease of the stomach is frequently met with; 
this organ ranks next to the uterus in the list of mortality from this 
cause. Primary cancer exists in the majority of cases. Dr. Walshe 
speaks of secondary " as almost unknown," except where it invades the 
organ from extension of adjacent growths. It is not uncommon to find 
a solitary growth in the stomach, no other part being implicated, as in 
a case we have recently examined. "The pylorus," says Rokitansky, 
" indifferently at all parts of its circumference, is known to be the chief 
seat of primary fibrous and areolar cancer of the stomach. From this 
point the degeneration extends chiefly along the lesser curvature over 
the pyloric half of the stomach; in many, though severe cases, it affects 
the entire stomach, attacking the fundus last, which, however, generally 
remains partially free. The parietes of the stomach may attain an inch 
in thickness, being rigid and generally tuberculated on their inner sur- 
face ; the cavity of the stomach will at the same time be diminished in 
size." Dr. Walshe states that cancer of the orifices may extend to the 
duodenum or the oesophagus. Rokitansky affirms " that cancer of the 
pylorus is accurately bounded by the pyloric ring, and never extends 
to the duodenum," whereas, cancer at the cardia invariably involves a 
portion of the oesophagus. We certainly think that scirrhous disease 



ABNORMAL CONDITIONS OF THE STOMACH. 477 

of the pylorus does not extend much beyond its original site, at least 
along the intestine, although it may propagate itself to the head of the 
pancreas, or the adjacent lymphatic glands. Commonly, as Rokitansky 
describes it, the scirrhous pylorus is bound down by the degeneration 
of the tissues lying behind it ; but, in other cases, it remains movable, 
and may be felt as a distinct tumor having descended more or less over 
to the lower part of the abdomen. The pylorus, the cardiac orifice, the 
greater, and, lastly, the lesser curvature are liable, according to the 
order in which we have placed them, to be the seat of cancer. Fibrous 
cancer undoubtedly is the most common, i. e. scirrhus, or, as we are 
inclined to think, a combination of scirrhus with colloid. Medullary 
cancer ranks next, according to Rokitansky, and areolar or colloid last. 

Fig. 216. 




Scirrhus Pylori. At the diseased part, the walls of the stomach are extremely thickened, and of a whity color. 

He notices the frequent primary combination, and the yet more frequent 
secondary, of scirrhus with encephaloid, or of both with colloid. The 
following description was taken from an exceedingly well-marked speci- 
men of scirrhus pylori, in which the walls of the passage were so thick- 
ened as to be nearly an inch in diameter. The cut surface presented a 
whity grayish tissue, contrasting well with the injected mucous mem- 
brane, and exhibiting a distinct striation vertical to the axis of the 
canal. A section under the microscope showed grayish-white bands, 
separated here and there by transparent gelatinous matter. The bands 
consisted of homogeneous, faintly-mottled substance, occasionally divi- 
sible into fibres closely resembling those of organic muscle, and, like 
them, exhibiting elongated nuclei when treated with acetic acid. Towards 
the mucous membrane this close stroma was replaced by a loose fibroid 
tissue, forming circular loculi of various sizes, which were filled with 
very various forms of cell-growth. Among them granule-cells were 
often apparent, but the main mass consisted of nuclei and low develop- 
ments of them. Some large mother-cells were seen, containing several 
well-formed nuclei and granulous matter : in the interspaces between 
the fibrous bands these mother-cells had attained a gigantic size, and 
appeared to constitute the loculi ; one of them was distinctly bifurcated 
at its narrow end, and the branches were of some length. Dr. Bennett, 
v. p. 43 of his work, doubts the cell character of these conglomerate 



473 ABNORMAL CONDITIONS OF THE STOMACH. 

masses, chiefly from the absence of a cell-wall. We are, however, 
inclined still to believe that the loculi, in this instance, and in colloid 
generally, resulted from the development of an endogenous growth 
■within, parent cells. In this case, we consider that there was a combi- 
nation of colloid with scirrhus, the former being constituted by the cel- 
loid substance. In Dr. Bennett's xxi. Observation, the alteration 
which had taken place in " the walls of the stomach was wholly of a 
fibrous character." No cancer-cells were detected, only elongated and 
fusiform nuclei ; but they were numerous in the enlarged mesenteric 
and lumbar glands. This latter circumstance is, we think, decisive of 
the truly cancerous nature of the morbid change in the stomach. Such 
a case may then be regarded as one of pure scirrhus, upon which ence- 
phaloid growths are sometimes secondarily developed, appearing as 
fungus or cock's-comb-like bleeding excrescences. Encephaloid, how- 
ever, either in the form of knotted tumors, or degeneration of the sub- 
mucous tissue, or infiltration of new-formed erectile tissue, sometimes 
occurs primarily. 

Colloid cancer, affecting the stomach, behaves much as it does else- 
where ; it originates, as the other species generally do, in the submu- 
cous tissue, and, as in a case excellently described by Dr. Walshe, may 
cause atrophy and destruction of the mucous membrane, over a more or 
less considerable space. We agree with this observer, that colloid may 
also be developed in the mucous membrane itself; for we have seen, in 
examining the mid-region of the stomach affected with scirrhus pylori, 
two large oval cysts, or cells, lined by a vesicular epithelium, and full of 
a clear fluid in the substance of the mucous tissue. It seems not impro- 
bable that these would have developed into a colloid growth, especially 
as the scirrhous formation contained loculi, somewhat similar to those 
described in the former observation. The mucous membrane, covering 
the cancerous growth, may undergo various changes. " It sometimes 
degenerates into an areolar cancerous tissue, which discharges large 
quantities of gelatinous mucous fluid ; or it is converted into erectile 
tissue as a fungoid growth, which becomes the seat of encephaloid infil- 
tration, suppurates, and partially exposes the submucous scirrhous cel- 
lular tissue ; or, lastly, it most frequently becomes the seat of a sloe- 
black softening, with hemorrhage," or it is quite destroyed, and the 
sloughing process attacks even the denuded scirrhus itself. In a speci- 
men we recently examined of scirrhus pylori, where the mass, limited 
to the pyloric region, was exposed on its inner surface, forming a 
sloughy ulceration with elevated, thickened margins, a fatty transfor- 
mation had very evidently commenced. It was most apparent in the 
contents of the loculi, which, in some parts, consisted of well-formed 
nuclei and granulous matter, but, in many others, only of an amorpho- 
granulous substance, imbedding much oily matter. It is conceivable 
that the further progress of this change might have effected a cure. In 
this case it was very distinct ; and it is worthy of remark, that, while the 
muscular coat had undergone very considerable hypertrophy, it was in 
no degree affected by the cancerous disease. This, though encircling 
the pyloric outlet, had not caused any actual obstruction to the passage, 
nor was the stomach distended in any very considerable degree. The 



ABNORMAL CONDITIONS OF THE STOMACH. 479 

cause, therefore, of the hypertrophy of the muscular coat does not seem 
sufficiently explained. 

A case is recorded by Andral, in which enormous dilatation of the 
stomach had taken place, although the pyloric orifice was free, and even 
larger than natural. He accounts for this by the non-existence of mus- 
cular fibres in this instance in the vicinity of the pylorus. Admitting 
this explanation, we are inclined to think that the very alteration of the 
natural condition of the outlet, its being reduced to a passive and rigid 
orifice, may necessitate a greater exertion of the muscular fibres, which, 
if it fails to take place, and thus induces a conservative hypertrophy, 
dilatation must result. Dr. Walshe, after mentioning the more usual 
occurrence of dilatation ensuing when the pyloric opening is obstructed, 
and contraction when the cardiac is, the size remaining unchanged when 
the body of the organ alone is affected, notices as "less intelligible" the 
fact to which we have just referred. He also remarks that, "as a gene- 
ral truth, the mucous membrane exhibits a notable power of resistance 
to the encroachment of the disease." This, we think, is true, at least 
as far as naked-eye investigation can ascertain; but in one case, where 
the mucous membrane appeared tolerably healthy, we found the tubular 
secreting structure in process of disorganization, not, however, from the 
extension of the cancerous disease. 

It is necessary to be on one's guard against confounding scirrhous 
cancer with simple induration and hypertrophy of the coats of the sto- 
mach. Rokitansky enumerates as distinguishing signs the preponderating 
increase of substance in the submucous cellular tissue, and its want of 
uniformity, the accompanying cartilaginous hardness and closeness of 
texture, the fusion with the mucous and muscular coats, and particularly 
the alteration in the muscular tissue itself. We think the microscope, in 
practised hands, would generally clear up all doubt. When loculi of 
cell-substance are mingled with the fibrous tissue, there can be little 
hesitation in regarding the growth as cancerous. If the structure is 
purely fibrous, attention must be directed to the limitation of the dis- 
ease, and to the existence of the infiltrating, softening, and contami- 
nating properties of cancer. Ulceration, usually the result of secondary 
gastric cancer, may cause perforation of the stomach and fatal perito- 
nitis; it more frequently happens, however, that effusion is prevented 
by the formation of adhesions between the threatened part and con- 
tiguous viscera. The liver and pancreas may thus become the seat of 
further cancerous invasion and destruction, or the ulcer may eat its way 
into the transverse colon, and thus cause an unnatural communication 
between its cavity and that of the stomach. A dark fluid, resembling 
coffee-grounds, is often found in the cancerous stomach after death, as 
well as vomited during life. In one case, where we examined it, we 
found it to consist of very numerous blood-globules, together with black 
granules and grains (probably altered haematin), and a very large quan- 
tity of amorphous, with some oily matter. It is to be remembered that 
vomited matter of this kind is not peculiar to cancerous disease ; the 
same may be brought up when there is simple exhalation of blood from 
the mucous membrane, common ulceration, or follicular ulceration, or 



480 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

even softening. The only circumstances necessary for its production 
are hemorrhage and the acid secretion of the stomach. 

Besides blood, there may be several other matters abnormally present 
in the stomach. Unhealthy mucus in large quantities, purulent and 
other exudations, bile, biliary calculi, fecal matter, and lumbrici, are 
more or less often met with. Foreign bodies, of the most various kinds, 
are also to be included in the list, as the sealing-wax, brick-dust, cinders, 
&c. swallowed by hysterical females, or those who are subjects of the 
morbid state termed pica, or by actual lunatics. A remarkable case of 
this kind has been recorded by Mr. Pollock, in the Report of the Patho- 
logical Society for 1851-52, in which the stomach was distended by a 
large mass of hair and string, while another occupied the lower portion 
of the duodenum and commencement of the jejunum. 



VI.— ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

The intestine is not unfrequently defective in some part of its course ; 
this most commonly is the case near its lower termination, and involves 
an imperforate condition of the anus (atresia ani). Sometimes the in- 
testine is only unusually short and of uniform caliber, or consists of 
several detached ccecal portions, or it may terminate at the umbilicus, 
or in a cloaca common to it and the genito- urinary organs. Andral 
refers to a case in which there was only a single straight canal, extend- 
ing from the termination of the oesophagus to the commencement of the 
rectum, to another in which the duodenum was double, a third in which 
there were two colons, to a fourth in which the appendix vermiformis 
was unusually large, and at the same time double. All these, except 
the first, are instances of excessive development, though Rokitansky 
refuses to regard them as such, and considers them as " arrests of for- 
mation." Among these, he especially includes the diverticula, which 
are not very unfrequent, and which deserve a particular description. 
Andral compares them to the fingers of a glove, and states that they 
form ccecal appendages, one or more in number, which are given off 
from the intestine at various points, and communicate with its cavity. 
They are most frequent at from 18 to 24 inches from the termination of 
the ilium, according to Rokitansky, but have been seen in the jejunum, 
the duodenum, and even in the rectum. Their length is various; some- 
times only a few lines, sometimes several inches ; their cavity may be 
equal, greater or less than that of the intestine with which they commu- 
nicate. It is most usual to find but one, but as many as six have been 
met with, originating from the same portion of intestine at a little dis- 
tance from each other. In structure, they are sometimes identical with 
the intestine; sometimes their several coats appear to be hypertrophied ; 
sometimes, on the contrary, more or less imperfectly formed. Meckel 
has founded on this difference a distinction of these diverticula into true 
and false. The false might be regarded as produced by a mere hernia 
of the mucous membrane, such as occurs in the bladder. True diverti- 
cula, Meckel considers to be formed by the non-closure of the vitelline 
duct at the usual spot, so that a portion of the canal, of varying lengths, 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 481 

remains open after the intestine is fully developed. Rokitansky does 
not quite assent to this view, but still believes that "it evidently has its 
origin in the development of the intestine in the umbilical vesicle." We 
are inclined to join with Andral in doubting the correctness of Meckel's 
theory. It is not by any means shown that the multiple diverticula 
occasionally found are produced by a hernial protrusion of the mucous 
membrane. The distal extremity of these offsets is generally free, 
sometimes adherent to the parietes of the abdomen, or to the mesentery, 
or to a loop of intestine. Occasionally, it is open; Meckel met with an 
instance in which a diverticulum terminated at the umbilicus, leaving an 
orifice by which a probe could be introduced into the intestine. The 
omphalo-mesenteric vessels were persistent also, accompanying the 
diverticulum ; so that in this case, at any rate, Meckel's view would 
appear justified. A case is recorded by Dr. Lionel Beale, in the Report 
of the Pathological Society for 1851-52, in which fatal peritonitis en- 
sued from softening and perforation of the lower part of a diverticulum, 
which was twice as broad there as in the upper part adjoining the intes- 
tine. It is very conceivable that these offsets, like the appendix vermi- 
formis, may become sources of danger by offering a favorable situation 
for the lodgement of cherry-stones, or other indigestible matters. Roki- 
tansky gives the following description of the characters of "false diver- 
ticula," which he regards as mere hernioe of the mucous membrane, 
"resulting from the separation of the fibres of the muscular coat." 
They consist solely of mucous membrane and peritoneum. They occur 
at any part of the small and large* intestines. " They are found in con- 
siderable numbers. They occur from the size of a pea to that of a 
walnut, in the shape of round baggy pouches of the mucous membrane. 
They form, more especially in the colon, nipple-shaped appendages, 
which occasionally are grouped together in bunches ; when occurring in 
the small intestine, they are commonly developed on its concave side, 
and are therefore placed between the layers of the peritoneum ; when 
in the colon, the feces are retained by them, and dry up into stony 
concretions." Uniform dilatation of the intestine may take place either 
from inaction of the muscular coat, or from distension from accumula- 
tion of its contents above a stricture. Disease of the nervous centres, 
inflammation of the serous investments, or simple atony of its contractile 
fibres, may be the cause of paralytic inaction and consequent distension. 
When a stricture exists, enormous dilatation sometimes takes place. 
Andral relates a case in which the large intestine was so distended that 
it resembled that of a horse, and concealed almost all the viscera. In 
such cases, the muscular coat may be in full and painful activity, not 
ceasing its action, although unable to overcome the obstruction, but 
reversing it so as to produce fecal vomiting. 

Contraction of the intestine may occur either throughout a consider- 
able extent, or in a very small one. The first is not a condition of 
disease, though it has been mistaken for such, and results merely from 
the canal at that part being empty for some time ; so that the natural 
contracting efforts of the circular fibres are unopposed, and the sides of 
the tube are brought together. We have seen the descending colon in 
this way so shrunk as to be scarcelv larger than the little finger. Of 
31 



482 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

course this condition is most likely to occur in the part of the intestine 
below a stricture. The second kind of contraction of the intestine is 
almost always morbid, and may result either from external pressure, as 
from a strangulating band, or compressing tumor, or from disease of the 
tissue in the part affected. The cicatrix of a simple or tuberculous 
ulcer, which had assumed an annular form, or a cancerous growth of 
like shape, has, in most instances, been the cause of stricture originating 
in the intestine itself. 

Changes in the position of the intestine leading to morbid effects, 
require some particular notice. The most common of these constitute 
the several varieties of hernia. As these are fully described in all 
surgical works, it does not seem necessary to make mention of them 
here ; and we shall, therefore, confine our attention, following Roki- 
tansky, to the morbid changes of position which befall the intestine 
within the abdominal cavity. A portion of intestine may be twisted 
upon its own axis, so as to obstruct the canal by the approximation and 
contact of the walls. This seems to have been observed only in the 
ascending colon. The mesentery may be twisted upon itself, forming 
a kind of cone, with more or less of the intestine attached to its base, 
which becomes strangulated by being twisted round the mesentery. 
"One portion of the intestine, either single or double — a coil — may 
afford the axis round which another portion with its mesentery is thrown, 
so as to be throughout in contact with the circumference of the axis, 
and thus to compress it like a ferule. A coil of small intestine, the 
sigmoid flexure, or the coecum, may form the axis." Abnormal length 
of the mesentery probably predisposes to these affections. More fre- 

Fig. 217. 




Strangulation of intestine by a portion of it slipping through an opening in the mesentery or omentum. 

quent than the foregoing, are the instances in which a portion of intes- 
tine, generally the small, becomes strangulated by consequence of 
having got into one of the following situations : (1) into the fissure of 
Winslow ; (2) into an opening in the mesentery ; (3) into an opening 
in the omentum; (4) into spaces included by corded bands of false 
membrane, and various parts of the abdominal viscera; (5) into similar 
spaces formed by a long vermiform process, or intestinal diverticulum. 



ABNOKMAL CONDITIONS OF THE INTESTINAL CANAL. 483 

The colon and the rectum have been known to be compressed and 
obstructed by a mass of loaded small intestine lying upon them ; and 
Andral refers to a curious case in which the transverse colon, in a child 
of six months old, was compressed between the duodenum and the ver- 
tebral column. These varieties of incarceration occur at every period 
of life; they are more common, Rokitansky avers, in the female sex 
than in the male, because the sexual organs of the former not only offer 
an additional point of attachment for constricting bands, but may also 
themselves give rise to constricting growths. The consequences of 
strangulation taking place in any of the above ways are distension of 
the intestine above the compressed part, peritonitis and ileus : the incar- 
cerated portion in the cases where there is much pressure on the mesen- 
teric vessels, is peculiarly liable to congestion and gangrene. Andral 
well remarks that the mere existence of the bands of adhesion, forming 
the orifices above described, by no means necessarily involves a strangu- 
lation of the intestine ; this, however, in such cases, may come on very 
rapidly when the included portion of intestine becomes distended from 
any cause. In some cases symptoms are observed for several months 
or years, indicating that some impediment to the free passage of the 
intestinal contents exists. Dr. Peacock has related, in the Report of 
the Pathological Society for 1848-49, two cases of so-called mesocolic 
hernia ; the small intestines being contained in a sac, formed by the 
layers of the mesocolon. In the first of these cases, there was no 
strangulation, though the ileum passed out of the sac over " a thin 
crescentic edge;" in the second, the ileum was strangulated at the part 
where it escaped. 

Invagination of the intestine implies the inversion of a portion, and 
its intrusion into another, an upper portion being generally intruded 
into a lower, and the converse rarely occurring. The following account 
we abbreviate from the very full details given by Rokitansky. Invagi- 
nations not uncommonly form, during the last moments of life, especially 
in diseases which give rise to irregular and disturbed innervation. 
Thus, they are often met with in the dead bodies of children who have 
died from hydrocephalus. They are characterized by the absence of all 
appearances of reactions, such as we shall presently mention, and by the 
parts being easily restored to their proper situation. Several often 
occur in the same case. When they occur during life as a primary 
affection, or consecutive only to diarrhoea, they speedily bring the 
patient into a condition of extreme danger. Every intussusception 
must present at least three layers, as will be readily comprehended on 
viewing the accompanying diagram : the outer, called the sheath, is 
formed by a portion of intestine in its natural position ; the middle is 
formed by the portion of intestine immediately above, which is inverted; 
so that its mucous surface looks outward, and is in contact with the 
mucous surface of the sheath ; the inner is the portion of intestine 
next above, with its serous surface opposed to that of the middle layer, 
which is simply intruded into the canal beyond it. Five layers will 
exist if another portion of intestine be forced down, and inverted into 
the original intussusception, which then becomes a sheath to it. 
"Between the middle and inner layers there is a portion of mesentery 



484 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 



Fig. 218. 




Diagram of intussusception. 

(a) The sheath. 

(b) The receding or inverted tube, 

(c) The entering tuhe. 



corresponding in size to that of the intestine displaced, and folded up so 
as to represent a cone, the apex of which lies at the free termination of 
the volvulus, with its base in the sheath, and at 
the entrance to the invagination. This portion 
of mesentery is always in a state of tension, 
which chiefly affects the part belonging to the 
inverted tube, and has a singular influence 
upon the form of the volvulus. It is the cause 
of the following circumstances : Firstly, that 
the volvulus (the middle and inner layers) does 
not lie parallel to its sheath, but always offers a 
greater curvature than the latter ; the inverted 
tube (the middle layer) being compressed in its 
concavity into tense transverse folds. Secondly, 
that the orifice of the volvulus does not lie in 
the axis or in the centre of the sheath, but 
external to it ; and that, following the traction 
exerted upon it by the mesenteric fold that 
belongs to the inverted intestine, it is directed 
towards the mesenteric wall of the sheath; that 
it is not circular, but represents a fissure. Intus- 
susceptions occur with equal frequency in the colon, and small intestine; 
but several cases occurring in the former are remarkable on account of 
the magnitude they attain. In these, the sheath contained a very 
long portion of the colon and ileum; both may be inverted two or three 
times, and the intussuscepted part advances to the vicinity of the anus." 
Contraction of one part and distension of another, are probably the con- 
ditions which give rise to invagination ; the upper contracted portion, 
whose muscular coat is for some distance upwards in a state of activity, 
being propelled onward into the dilated part below. Disordered and 
irregular innervation is probably the remote cause, in this as well as 
in the case of intussusceptions taking place during the agony. Increase 
of the invagination always takes place by more and more of the intes- 
tine becoming inverted, so that the. upper border of the middle layer is 
continually shifted lower down. The consequence of invagination is, as 
may be expected, peritonitis and its results. Inflammatory congestion 
is set up, not at first, in consequence of annular constriction of the vol- 
vulus, but from compression of the vessels ; especially the veins of the 
portion of mesentery which is dragged down by the advancing and in- 
verted layers. This obstruction to the circulation, Rokitansky says, 
gives rise to violent inflammation with " plastic effusion on the con- 
tiguous serous surfaces of the entering and receding (inverted) tube, 
and upon the mucous membrane of the latter. The inverted portion is 
invariably the one that suffers most;" " and it is characteristic, that, 
even when the inflammation of the volvulus runs high, its mucous mem- 
brane remains pale." The sheath is not so much affected except in 
large invaginations. The tumefaction resulting from the inflammatory 
congestion may cause strangulation of the volvulus, usually at the 
entrance, but sometimes at other points. If death does not result from 
the peritonitis, the ensuing gangrene, or the strangulation, recovery 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 485 

takes place with one of the three following terminations to the morbid 
process : (a) Complete adhesion having been formed between the two 
opposed serous surfaces of the sheath, and the inverted tube at the point 
of inversion, the whole contained volvulus mortifies and is thrown off, 
and becomes discharged per anurn. In a case referred to by Andral, 
the portion of intestinal tube thus evacuated, measured eighteen inches ; 
and He'vin relates two cases, in one of which twenty-three inches of 
the colon were thus parted with, and in the other twent}^-eight inches 
of small intestine. An annular swelling, more or less interfering with 
the canal of the intestine, is found in the corpses of persons in whom 
this termination has occurred, besides adhesions of the serous surfaces 
in the vicinity, (b) "In rare cases, in which the incarceration has been 
developed at an unusual point, only a partial sloughing of the volvulus 
takes place ; and the portion which lies above the strangulation is 
retained. Under these circumstances, the latter forms a conical plug 
with a narrow channel, and projects into the cavity of its sheath, sur- 
rounded by a thick fringe of mucous membrane." (c) Occasionally, 
after adhesion has taken place, the inflammation abates, and the vol- 
vulus is retained. The first mode of termination is the only one that 
produces a permanent recovery ; in the others, there always remains 
a degree of chronic hyperemia, with liability to exacerbation. No 
age is exempt from the occurrence of invaginations. Andral quotes 
from Monro a case of a very considerable one, in a child four months old. 
Prolapsus ani is an affection very analogous to invagination, differing 
chiefly in not having a sheath, as Rokitansky remarks, and also, as we 
think, in the peritoneum being less involved. In trifling cases, only a 

Fig. 219. 




Prolapsus Ani. 

fold of the mucous membrane comes down, but in the more serious, both 
the mucous and muscular tunics descend. The tumor thus formed is of 
a sausage or pyriform shape, pediculated by the contraction it undergoes 
at the anus, and having at its extremity, in the minor degrees, a round 
central orifice, and in the greater, an eccentric fissure. The results of 
prolapsus ani (more properly recti), are not, for the most part, nearly 
so serious as those of invagination. In some cases, indeed, strangula- 
tion takes place, the everted part swells to twice or thrice its proper 



486 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

size, assumes a red, purplish color, with an appearance of ecchymosis 
and of impending gangrene. More often, even in inveterate cases, 
there is only a discharge from the irritated or mucous membrane of a 
thin muco-sanguineous fluid, with, perhaps, some superficial ulceration. 
In some cases the epithelium of the mucous surface, from constant ex- 
Fig. 220. 




Prolapsus Ani. 



posure, assumes a cuticular character. The affection is of common 
occurrence in children, for which Sir B. Brodie assigns the following 
reason: "The attachment of the rectum to the surrounding part does 
not extend so high in children, as in persons of mature age ; while the 
reflection of the peritoneum takes place lower down; and hence the 
rectum is more liable to be pushed out." 

Wounds and lacerations of the intestines demand a brief notice. 
When the bowel is wounded by the thrust of a cutting instrument, the 
danger of escape of the intestinal contents, and of consequent perito- 
nitis, is not so extreme as might be supposed. The mucous membrane 
being somewhat loosely attached and thrown into natural folds, protrudes 
at the orifice so as to close it, if it be not very large; at the same time 
the constant pressure of the parietes tends to keep the wounded point 
applied against the opposing surface, to which, moreover, it becomes 
glued before long by adhesive exudation. If an opening is made into 
the intestine by ulcerative perforation of its wall, the effusion of lymph 
uniting it to adjacent parts becomes occasionally the medium through 
which a fistulous communication is established, either with the exterior 
of the body, or with another hollow viscus in the vicinity. Sometimes 
the ulceration, instead of penetrating further, causes simply the forma- 
tion of abscess in the sub-peritoneal cellular tissue, fecal abscess, as it is 
termed. When the intestine is divided completely across, the two ends 
will occasionally unite, if brought together and maintained in apposition 
by stitches; but no one has yet succeeded in repeating Kamdohr's experi- 



ABNOKMAL CONDITIONS OF THE INTESTINAL CANAL. 487 

ment (said to have been successful), in which a large portion of an 
intestine having mortified, was cut off, and the upper end inserted within 
the lower, and kept in that position by a suture. It is very unlikely, 
that a mucous and a serous membrane would unite by adhesions, which 
is said to have occurred in that case. 

The muscular coat of the intestines is very rarely, if ever, primarily 
the seat of inflammation, though it very often is involved by extension 
of the mischief from the serous or mucous tunics. We have, therefore, 
now to consider chiefly the condition of the mucous membrane and its 
follicles when inflamed. It must be premised that no kind or amount 
of vascular injection can be accepted by itself as a decisive proof of the 
existence of inflammation. Obstruction to the free return of blood by 
the veins, according to the degree in which it exists, will produce rami- 
form, patchy, or general injection; and the same cause will also give 
rise to the punctiform, which has been thought more characteristic of 
active hyperemia. Very marked injection also results from mere gravi- 
tation of the blood after death to the most depending parts. MM. 
Trousseau and Rigot found in dogs, which had been suspended after 
strangling in a vertical position, the blood collected in those parts of 
the intestines which were the lowest, giving the mucous membrane and 
its villi a deep red tinge, and extravasating itself on the surface and in 
the submucous tissue. When the bodies were suspended in the reverse 
position, the same effects took place in those that were then the lowest. 
This hypostatic congestion is especially liable to take place in fevers, in 
severe cases of which, the blood is so commonly found fluid after death. 
Redness, resulting from mere staining of the tissues, is sometimes very 
similar to that of active hyperemia. The injection which takes place 
from engorgement of the veins may be distinguished from that of in- 
flammation, by the circumstance of its being always traceable to dis- 
tended veins, and, further, we think, by the redness being more general 
than that of inflammation commonly is. In general, the smaller and 
more isolated the patch of injection is, the more likely is it to be inflam- 
matory; thus, we find small separate patches of injection around com- 
mencing typhous deposits, which contrast with the generally pale mucous 
membrane. 

Inflammation, affecting chiefly the mucous lining of the intestines, was 
distinguished by Cullen as enteritis ery thematic a. It corresponds to 
the muco-enteritis of others, especially the French pathologists. Roki- 
tansky speaks of it as catarrhal inflammation, which may be either acute 
or chronic, and either attack the mucous membrane uniformly or be de- 
veloped mainly in the villi and the follicles. It is excited by various 
causes of irritation, and especially by certain atmospheric influences. 
"The anatomical signs of the acute form are, more or less intense red- 
ness and injection of the mucous membrane, affecting its entire surface, 
or appearing as punctiform reddening from affection of the villi, or as a 
vascular halo surrounding the follicles ; relaxation of the tissue, and 
intumescence of the mucous membrane, equally affecting the entire sub- 
stance, or only the villi and follicles ; opacity of the mucous membrane 
and its epithelium, from infiltration of the former and softening of the 
latter ; friability and softening of the mucous membrane. The sub- 



488 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

mucous cellular tissue is injected, relaxed, and infiltrated with a watery, 
opaque fluid; the secretion is at first copious and serous; as the affection 
increases in intensity, the former diminishes in amount, becomes opaque, 
viscid, and puriform. 

Chronic inflammation is characterized, in addition to the above signs, 
by a dark, rusty, livid discoloration, which, in severe cases, appears to 
pervade the entire mucous membrane ; by a tumid state of the mucous 
membrane and its follicles, accompanied by increased density of the 
tissue, copious secretion of an opaque grayish-white or yellow puriform 
mucus. The acute form may subside completely, or several relapses 
occurring, it may merge into the chronic, which seldom "admits of a 
complete cure." The following are the principal changes produced by 
chronic intestinal catarrh: (1.) A more or less abundant deposit of black 
pigment in the whole mucous membrane, or in its villi or follicles only. 
(2.) A permanent tumefaction of the mucous membrane, depending pro- 
bably on dilatation of its vessels and interstitial exudation, which causes 
increased density of its tissue, and may give rise, "in higher degrees, 
to elongation of the membrane, and formation of folds and polypi." 
(3.) Hypertrophy of the submucous cellular tissue and of the muscular 
coat. (4.) Profuse secretion of a grayish-white and milky, or of a trans- 
parent gelatinous and viscid mucus. Suppuration and ulceration some- 
times result from catarrhal inflammation, especially when an acute attack 
supervenes upon the chronic form. "The mucous membrane is converted 
into a dark-red, granulated, and friable tissue, on the surface of, and 
within which, suppuration is established." The burrowing of the ulcers, 
so as to pass through even the muscular coat, gives rise to sinuses, in the 
vicinity of which there is often a production of polypoid growths from 
the mucous membrane. Corrugation of, and pigmentary deposit in the 
tissues, are constant accompaniments of this process. Cicatrization of 
the ulcers and sinuses takes place, with formation of the usual fibroid 
tissue, which, by its subsequent contraction, may give rise to puckering 
or obstruction. Rokitansky states that the most usual seat of catarrhal 
inflammation is in the coecum and rectum ; we doubt if this is true, if 
applied both to the acute and chronic forms, for there can be no doubt 
that, in the majority of instances of muco-enteritis, the small intestines 
are affected even to a greater degree than the large. He observes him- 
self that "catarrhal irritation, and even inflammation, undoubtedly often 
affect the duodenal mucous membrane, and are frequently induced by an 
anomalous condition of the bile." This condition, as Dr. Stokes has 
observed, "may extend to the biliary ducts and give rise to jaundice, an 
instance of which we have lately had under our care. Besides the tume- 
faction of the mucous membrane, the increased pouring out of mucus, 
and the enlargement of the glands of Brunner in this situation, we have 
noticed an atrophy or destruction of the villi, which had lost their sharp 
exterior margin of limitary membrane, and were shreddy and wasted. 
The chronic form of catarrhal inflammation does seem to be more fre- 
quent in the large intestine, at least the slaty and black discoloration is 
more often seen in the coecum than elsewhere; but it may admit of some 
doubt whether this discoloration is a certain sign of previous inflamma- 
tion, whether a deposit of pigment may not take place here as in the 



ABNORMAL CONDITION'S OF THE INTESTINAL CANAL. 489 

areolar tissue of the lung, or in the skin, without any disease. We have 
certainly examined instances in which the microscope showed nothing 
the least abnormal except the pigmentary deposit. 

It seems very doubtful whether there is a distinct affection such as 
that which has been termed glandular or follicular enteritis. • Dr. Cop- 
land speaks of it as occurring almost always consecutively to other dis- 
eases, as fevers, continued or remittent, dysentery, and even tuberculosis. 
Rokitansky does not seem to recognize its special character, but to con- 
sider that the follicles may be more particularly affected in morbid pro- 
cesses of different kinds. In this opinion we entirely coincide, but wish 
to notice here an anatomical point which we think is not generally 
understood. The solitary glands of the intestine, which occur both in 
small and large, as well as their aggregations, constituting the patches 
of Peyer, which do not extend beyond the ilio-coecal valve, are quite 
destitute of the follicular character, that is, are not involutions of the 
general mucous surface, invested by a lining of epithelium. They are 
simply solid aggregated masses of nuclear particles, with very little 




Vertical section of Peyerian patch, and solitary gland of large intestine. The glands in hoth are rather 
enlarged, (a) Peyerian patch from ileum, (b) Solitary gland. 



intervening granulous matter, which lie completely beneath the sheet of 
basement-membrane that covers the surface. They are not contained 
in a distinct capsule of homogeneous membrane, but lie partly in the 
corium of the mucous tissue, partly in that layer of nuclei and granulous 
matter which is spread under the basement-membrane, and forms the 
chief substance of the villi, to which we gave, some years ago, the name 
of "substratum." It is apparent, from this structural arrangement, that 
they cannot be secreting organs like the Lieberkiihn tubes all round 
them, for they have no outlet. On the other hand, they are, from their 
very structure, peculiarly liable to become enlarged and prominent, the 
nuclei attracting to themselves plasma, and developing into cells. There 
seems no doubt that they are much more developed in some persons than 
in others, and we are much inclined to think that masses of precisely 
similar appearance may be formed in the mucous membrane, solely as 
the result of irritation. We have been led to this belief from having 
found only a few distant and widely scattered glands in the mucous 



■190 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

membrane of some persons, even when it was examined after immersion 
in acetic acid, which makes them much more opaque and white, while in 
other cases they were extremely numerous and close together. There 
really seems to be a good deal of resemblance between them and small 
pustules of the skin, like which, when the inflammation reaches a cer- 
tain point, they are extremely apt to suppurate and slough. We shall 
now subjoin Rokitansky's account of "ulcerative inflammation of the 
follicles of the colon, such as we find in lientery, brought on by tedious 
diarrhoeas. The follicles are at first tumefied in various degrees, and 
consequently project as smaller or larger round, conical nodules on the 
internal surface of the intestine, being surrounded by a dark-red vascular 
halo. Ulceration now ensues in the interior of the follicle, the small 
abscess penetrates the mucous membrane within the vascular halo, and 
a fringed ulcerated opening, of the size of a millet-seed, appears, which 
leads to a small follicular abscess with red spongy walls. The ulceration 
continues, and the follicle is eaten away," so that an ulcer of the size 
of a pea or lentil is formed. In its further progress, the mucous mem- 
brane becomes extensively destroyed, and that with great rapidity, the 
muscular coat being frequently exposed. The most extensive destruction 
always takes place in the sigmoid flexure and in the rectum. The dis- 
ease is always confined to the colon ; 4mt, when it runs a very rapid 
course, it may be accompanied by catarrhal irritation of the small 
intestine. We have notes of a case in which there were a great number 
of the so-called solitary follicles in the lower part of the small and in 
the large intestine, although no irritation had existed during life. Their 
development seems to depend on some other cause besides mere irritation, 
though this, no doubt, promotes it. Like the Peyerian patches, they 
are sometimes very prominent in cases of typhus, sometimes scarcely 
discernible ; and the same is true of common catarrhal irritation and of 
dysenteric. It can scarcely be supposed that the Lieberkuhn follicles, 
which are mere involuted extensions of the mucous surface, should not 
be affected wherever the mucous membrane is; but the solitary glands, 
which differ essentially in structure, seem to be by no means necessarily 
involved. 

We proceed to the other form of enteritis, that termed by Cullen, E. 
Phlegmonodea. The effects produced by this, which, indeed, are just 
those of common inflammation, have already been several times adverted 
to ; but we think it well to subjoin the following excellent description 
from the pen of Dr. Copland : "The villous coat in acute enteritis is not 
only more vascular and turgid, but it is also softer, and sometimes 
thicker than natural. If the inflammation has proceeded far, it pre- 
sents a brick-red tinge, and is easily detached from the subjacent coats, 
the connecting cellular tissue being soft, turgid, and inflamed. When 
this state exists in a considerable portion of the tube, the coats are ap- 
parently thickened, arising from the extension of the inflammation to 
the more external tissues, till the attached surface of the intestinal peri- 
toneum is reached. The substance or parietes of the bowels may be 
considered as affected in these cases, even although the external surface 
may present no further lesion than red vessels shooting into it. Occa- 
sionally, in addition to this state, the red capillaries in the inflamed 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 491 

peritoneal coat are connected with the effusion of coagulable lymph, par- 
ticularly in the parts where they are most numerous, the lymph or albu- 
minous exudation existing in specks, or in considerable spots or patches, 
on the serous surface. When, however, these latter appearances are 
remarked, the interior of the inflamed intestine frequently presents more 
serious changes than yet noticed. The villous surface is then deeply 
inflamed, and seems abraded or excoriated in parts. It is sometimes, in 
other parts, covered by patches of lymph, or of an albumino-puriform, 
or muco-puriform fluid, or by a sero-sanious matter ; and it is often also 
ecchymosed in numerous points or specks, or it presents still larger marks 
of sanguineous infiltration. In other cases, portions of a dark, slate- 
colored, or sphacelated hue are observed, with or without ulcerated 
specks, or even large ulcers, which have nearly penetrated as far as the 
external coat, in adjoining parts." Sometimes then ulcers actually 
perforate the intestinal wall, and give rise to escape of the contents. 
" In the forms of enteritis in which the substance of the intestine, or its 
peritoneal coat, is chiefly affected, either primarily or consecutively, the 
whole of the coats are often very vascular, red, or of a brick-red color, 
and are readily torn." Suppuration sometimes takes place between the 
coats, as in an interesting case recorded in the Pathological Society's 
Reports, 1851-52, by Dr. Hare. General peritonitis not unfrequently 
occurs, in which the omentum may markedly participate, becoming 
greatly thickened and red. 

The intestinal mucous surface is sometimes the seat of a kind of in- 
flammatory process, which is mostly subacute or chronic, and gives rise 
to an exudation much resembling that of croup. It is remarkable that 
the attacks often recur several times, each presenting a stage of irrita- 
tion, which ends in the formation and throwing off of the false membrane, 
after which there is a pause. The quantity of the exudation varies much 
in different cases; sometimes it forms a layer of some thickness, extend- 
ing pretty uniformly over the surface, or appearing in the stools as 
tubular casts of the intestines ; sometimes it is as thin as a wafer, or 
consists merely of tattered shreds. In one case, mentioned by Dr. Cop- 
land, there were also shreds of dysmenorrhoeal false membrane discharged 
^rom the uterus, but not at the same time as those from the bowels. 
Rokitansky mentions the occurrence of less consistent fibrinous exuda- 
tions, w^hich probably approach more or less closely to those of diphthe- 
ritis. They are, as he observes, " the expression of a constitutional 
affection," the results of an altered blood crasis. 

The changes which take place in the intestinal mucous membrane in 
continued fevers have been most diligently examined, and minutely de- 
scribed by Rokitansky ; but our limits forbid us to follow him closely, 
ahd we shall, therefore, only endeavor to give a short and comprehensive 
account of the various phenomena belonging to what he calls the typhous 
process. The intestinal affection, as is well known, is no necessary part 
of fever. We have examined the intestines of persons dying of fever, 
in which very little trace of Peyerian patches or solitary glands could 
be detected, certainly less than we have seen in the bodies of persons 
who have died from other diseases. When, however, the malady spe- 
cially affects this seat, we observe the following series of changes : Hy- 



492 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL, 



penemia, to a greater or less extent, is set up around the solitary follicles, 
and in and around Peyer's patches. Enlargement and distension of 
these glandular structures proceed nearly pari passu with the hyperseinic 
congestion. After a certain time, the length of which varies in different 
cases, the contents of the enlarged glandular masses soften, break down, 
and are discharged. The cavity which remains on the mucous surface, 
constitutes the typhous ulcer, to which Rokitansky attributes the follow- 
ing character : (1.) Its form is elliptical, round, or irregular, and sinuous, 
according to the shape of the part which has been affected. Thus, a 
large patch, when destroyed, gives rise to an elliptical ulcer ; a smaller 
or a solitary gland to a round one ; partial destruction of a patch will 
produce an irregular ulcer. (2.) The size of the ulcer varies from that 

of a hemp-seed to that of a half-crown. (3.) 
Those of an elliptic shape are always situated 
opposite to the insertion of the mesentery, 
and have their long axis parallel to that of 
the intestine. The typhous ulcer very rarely 
indeed forms a zone. (4.) " The margin of 
the ulcer is invariably formed by a well-de- 
fined fringe of mucous membrane, which is a 
line or more wide, detached, freely movable, 
of a bluish-red, and subsequently of a slaty 
or blackish-blue color. (5.) The base of the 
ulcer is formed by a delicate layer of sub- 
mucous tissue which covers the muscular coat ; 
like the marginal substance, it is quite void 
of morbid growth. (6.) The small intestine 
is the seat of the ulcerative process, and the 
lower third is most liable to be involved — the 
number and size of the ulcers increase as they 
advance towards the ilio-ccecal valve." We 
must add with respect to the last character, 
that the ulcerative process is by no means 
confined to the small intestine; we have seen 
the mucous membrane of the large intestine, 
down to the rectum, riddled with ulcers. 
They were many of them of large size, and 
had clean cut, non-thickened margins. This 
condition, indicating the absence of reparative action, is not nearly so 
frequent as that of thickening and induration, which generally takes 
place to some extent in the side of the ulcer. The bottom of the ulcer 
is commonly formed by the submucous tissue, sometimes the muscular 
fibres are completely exposed. This, however, Js generally the result 
of secondary advance, subsequent to the expulsion of the typhous deposit. 
Rokitansky particularly insists on the point, and we think he is correct, 
that when an ulcer increases in depth so as to perforate the intestine, 
it advances not by continued deposition and softening of typhous matter, 
but by simple extension of the ulcerating action. We feel inclined to 
doubt Rokitansky's statement respecting the extreme rarity of a typhous 
ulcer assuming a zonular form. We think we have seen some that in- 




Typhous ulcers in small intestine. 
Death from hemorrhage. The outline 
figures represent vertical sections. Tn 
the upper figure the margins of the 
ulcer are thickened; in the lower they 
are clean cut, as if punched. 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 493 

volved a considerable part of the circumference of the intestine, and 
Andral mentions a case in which there were a dozen ulcers encircling 
the canal like rings. It is true, he does not positively state that they 

Fig. 223. 




Inflamed mesenteric glands in Typhus and so-called typhous matter. At the lower and left part is repre- 
sented a small ulcer in the mucous membrane, in which ulceration is seen extending round the central 
typhous deposit, which is still in situ. 

were the result of fever, though this seems almost implied. The matter 
which causes the tumefaction of the agminate and solitary glands is 

Fig. 224. 




Typhous ulcers in various stages. The outline figures are vertical sections, which show the elevation of the 
mucous membrane hy submucous deposit, (a.) Mucous membrane, (b.) Submucous tissue, (c.) Muscular 
coat, (d.) Peritoneal coat. 



simply a kind of albuminous exudation, not differing we believe essen- 
tially from any other. It either, which is most frequent, forms a solid 
mass imbedding the natural nuclei of the gland, or affords a plasma, out 



494 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

of which these nuclei develop celloid particles. Black granules and 
grains of pigmentary matter are often present in it, but they are by no 
means peculiar to the typhoid state. They give to the glands a black 
dotted appearance, as seen by the naked eye, and this we have observed 
more than once after death from other causes than fever. The mesen- 
teric glands become invariably enlarged in all cases of intestinal affec- 
tion, just in the same way as an inguinal gland enlarges when there is 
a chancre on the glans penis. Their enlargement seems to be simply 
the result of irritation ; we have found nothing in their substance besides 
the normal nuclei but granular and amorphous matter, and some celloid 
particles or cells. The vessels of their capsule are generally much 
congested, as well as those which penetrate their interior. Rokitansky 
states that " the mesenteric glands decrease in size, as soon as the de- 
tachment of the intestinal morbid growth has commenced." Of course, 
they must remain for some time more congested with blood, and larger 
than natural, even under the most favorable circumstances. It by no 
means necessarily follows that ulceration takes place after a patch or a 
single gland has been enlarged; the exudation may liquefy and be again 
absorbed into the blood, and the part return to its normal condition. 
Cicatrization of the ulcers is not unfrequent, as Dr. Watson testifies. 
He says : "The ulcerated surface seems to clothe itself afresh, by degrees, 
with a new mucous membrane, which is thin, however, and adherent to 
the subjacent tissues, and does not slide over them when pressed between 
the finger and thumb, as the healthy portions of the coats of the bowel 
will do upon each other. And in the place of the cicatrix there is usu- 
ally to be seen a manifest puckering, and a number of little wrinkles or 
lines, radiating from a common centre." 

Rokitansky speaks of the new-formed membrane as a serous lamina, 
which becomes at its circumference as it were dove-tailed in between 
the muscular and mucous coats. He confirms the observation of Sebas- 
tian, that small villi sometimes form upon this lamina, even before its 
union with the mucous membrane. In most instances, however, the 
absence of villi forms one of the distinctive features of a cicatrix. We 
feel much hesitation in accepting Rokitansky's absolute assertion, that 
the cicatrix of a typhus ulcer never in any way gives rise to a diminu- 
tion of the caliber of the intestine. Dr. Carswell speaks positively of 
the occurrence of fatal ileus in persons who had suffered some months 
before from typhoid fever, the cicatrix of an ulcer being found after 
death, which had destroyed the muscular coat around the whole circum- 
ference of the tube. 

The morbid changes in Dysentery have their especial seat in the large 
intestine, the ileum being sometimes (Dr. Copland says very often) in- 
volved, but always in a less degree. Our observation quite accords 
with Rokitansky's, that " as a rule its intensity increases from the 
coecal valve downwards," so that the sigmoid flexure and the rectum are 
found most severely affected. It commonly runs, Rokitansky says, an 
acute course, " though it is frequently chronic in the milder degrees ; 
this, however, does not materially alter its character." Dysentery 
presents itself to the medical observer under a very great variety of 
forms, but it would be impossible to range the post-mortem appearances 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 495 

in corresponding groups. All that can be said in general, is that both 
the symptoms during life, and the textural lesions, will coincide in in- 
dicating whether a given case is to be considered of sthenic or asthenic 
character. Looking, then, upon dysentery generally as inflammation, 
more or less acute, of the mucous membrane of the large intestine, and 
premising that it is very prone to pass on into a lingering chronic state, 
we shall follow Rokitansky's account of the changes produced by the 
disease. He considers them "as divisible into four natural degrees." 
In the lowest, the mucous membrane in its projecting folds is injected, 
swollen, and softened, its surface seems excoriated, the epithelium is 
detached as a grayish-white layer, or elevated by effusion into small 
vesicles containing serum, as in a case we witnessed, or it may be min- 
gled with amorphous matter in an exudation of dirty gray and reddish 
color covering the surface. Dr. Baly, who mentions the detachment of 
the epithelium and its mingling with amorphous matter, describes the 
solitary glands in his first stage as being enlarged, forming round promi- 
nences, which, in a chronic state, by sloughing and ulceration, assume 
the form of open sacs. The mucous and submucous coats become thick- 
ened. " In the second degree, the textural alterations are not limited" 
to the projecting folds, " but extend over a larger surface, still, however, 
presenting a greater development at one part than at another." The 
mucous membrane is invested to the same extent, by a dirty, gray layer, 
consisting of desquamated epithelium and a thick glutinous exudation ; 
or this may already have been removed, and the subjacent mucous mem- 
brane, in either case, appears converted into a soft, sanguineous, pale 
red and yellowish gelatinous substance, which may be easily detached." 
The submucous tissue becoming infiltrated, gives rise to more or less nu- 
merous protuberances, on the internal surface of the intestines; these 
correspond to those points of the mucous membrane, at which the 
morbid affection is most developed," while in the intervening portion, 
there is not much change beyond slight redness and swelling. The in- 
testinal cavity is dilated by the pressure of exhaled gas upon the semi- 
paralyzed muscular coat, and contains a mixture of effused lymph and 
blood, together with mucous liquid and feces. Dr. Baly marks his 
second degree by the sloughing of the solitary glands, either principally 
or equally with the surrounding mucous membrane. In this way are 
formed either clear circular ulcers of various depth, or large excavations. 
The prominent rugae are chiefly affected. Rokitansky also remarks, 
that the affection of the follices may predominate, and states that the 
anatomical condition is the same as that already described in connection 
with catarrhal inflammation as attendant upon lientery. "In the third 
stage, the protuberances are set more closely together, the mucous 
membrane investing them partly retains the same condition as in the 
former, partly" is converted into a slough, which is here and there 
blended with the desquamated epithelium " and the exudation, and is 
firmly attached to them ; it is of a dark-red, or blackish-brown, or gray- 
ish-green color." In some cases, the infiltrated and thickened submu- 
cous tissue is in great part exposed, being covered here and there by 
the remnants of the mucous membrane, "in the shape of solitary, dark- 
red, flaccid, and bleeding vascular tufts, or as dilated follicles, which 



496 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

are easily removed." The protuberances are occasionally found to 
have coalesced, and the intestine then presents an uneven plicated sur- 
face, accompanied by an equal degree of infiltration and thickening of 
its parietes ; the mucous membrane is uniformly affected over a large 
extent, and there are no free interstices. The contents of the intestine 
are of a dirty brown or reddish, ichorous, fetid, flocculent, and grumous 
character. 

In the fourth and highest degree, the mucous membrane degenerates 
into a black, friable, carbonified mass, which may often be subsequent y 
voided in the shape of tubular laminae (so-called mortification of the 
mucous membrane). The submucous cellular tissue appears to be pre- 
viously infiltrated with carbonified blood, or a sero-sanguinolent fluid ; 
or it is pallid, and the blood contained in its vessels is converted into a 
blacky solid, or pulverulent mass ; subsequently, it shows purulent in- 
filtration, in consequence of the reactive inflammation which is induced 
in the lower, healthy strata, for the purpose of eliminating the gan- 
grenous portions. Dr. Baly's third degree seems to correspond to the 
fourth of Kokitansky; he describes the mucous membrane as converted 
into a gangrenous slough, glands and all alike, the blood being dark 
and coagulated in the submucous tissue. The prominent rugae are first 
and most severely affected, the intervening portions being swollen and 
red. All the coats sometimes are much softened, and the submucous 
tissue becomes sloughy. The changes just enumerated as occurring in 
the most extreme degree of the disease, are of much the same kind as 
those which Dr. Copland describes to take place " in the most malig- 
nant varieties, and in the scorbutic complication. The internal surface 
of the whole digestive tube is," in these cases, " of a livid purple, or 
dark color, with patches of ecchymoses, excoriation, ulceration, and 
sphacelation. The villous coat, particularly in the seat of ecchymoses, 
may readily be rubbed off; and the ulcers have a foul and dark appear- 
ance. The liver is sometimes large, soft, and spongy ; at others, pale 
and soft, especially in cases where the loss of blood has been very large. 
The spleen is sometimes so softened as to appear semi-fluid or sphace- 
lated. The heart is often partially softened or flaccid ; the pericardium 
and pleural cavities containing a bloody, dark, and dirty serum. The 
lungs are often congested; the bronchial lining dark or ecchymosed ; 
and the blood, in all the large vessels, is semi-fluid, black, and of a very 
loose texture." "In prolonged inflammatory cases, thickening and 
almost cartilaginous induration of a considerable part of the colon are 
not unfrequent, the thickened or indurated portion being also contracted 
in caliber. In such cases, the parts above the contraction are greatly 
distended, the coats being thinned, ulcerated, and even lacerated •/' so 
as to give rise to effusion and fatal peritonitis. The darkly-con o-ested 
mucous membrane is often discernible through the peritoneal and°other 
coats, especially if, as is often the case, the intestine is distended. In 
the severer cases, the serous membrane is dulled and discolored, and 
sometimes covered with a brownish ichorous exudation. The mesocolic 
lymphatic glands are swollen and congested. In the dysentery which 
occurs in this country, abscess of the liver is rare ; a case, however, is 
recorded in the Report of the Pathological Society, 1851-52. Dr. Baly 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 497 

has never met with it during his experience at the Millbank Penitentiary, 
where the disease is very common ; but in India, it is said to occur in 
nearly half the cases. We have recorded, in the Report of the Patho- 
logical Society, 1847-48, an instance in which the destruction of the 
mucous membrane was confined to the interstices of numerous promi- 
nences or ridges, these being themselves the sole remnants of the mucous 
tissue. This is the converse of the more usual condition, in which the 
prominent parts are most affected. After extensive ulceration has oc- 
curred, reparation may be effected in the usual way by organization of 
plastic exudation into a smooth fibroid layer which constitutes a cicatrix. 
This probably may be covered after a time by an epithelial layer ; but 
it has not been shown yet that the follicles of Lieberkiihn are repro- 
duced. When extensive destruction of substance has taken place, the 
cicatrix tissue " is frequently condensed into fibrous bands, which form 
corded projections into the intestinal cavity, interlace with one another, 
and not unfrequently encroach upon the caliber of the intestine in the 
shape of valvular or annular folds, thus giving rise to a stricture in the 
colon of a very peculiar form." Instead of reparation taking place, 
the disease may continue in a chronic though altered form; the remain- 
ing mucous membrane being in a state of chronic catarrhal inflammation, 
and the intervening parts being the seat of suppuration with formation 
of sinuses and abscesses. 

G-elatiniform softening, analogous to that described as affecting the 
stomach, occurs also in the intestines, but much less frequently. "It 
involves," Rokitansky says, "the external coats, converts them into an 
homogeneous, grayish-red, transparent, and deliquescent gelatin, and 
leads to spontaneous perforation." It is far more often met with in chil- 
dren than adults, and seems to be occasioned by unsuitable food, bring- 
ing up by hand, and generally by causes which depress the organic 
nervous power; diarrhoea, absence of fever, and great and increasing 
debility, are the prominent symptoms. Dr. Droste, quoted by Dr. Cop- 
land, distinguishes three stages of the softening process ; in the first, 
the villous surface retains its texture, but loses its consistence more or 
less extensively; in the second, it is converted into a thin, soft, gelatin- 
ous and nearly transparent substance, capable of being washed away; 
in the third, "no trace of organization is left in any of the coats," which 
are perforated, or on the point of being so, in various places. Fatty 
tumors, sessile or pediculated, occur in the intestinal canal ; they origi- 
nate in the submucous tissue, where fat-vesicles always exist, and grow 
inwards. Serous and fibro-serous cysts are met with but very rarely 
between the intestinal coats. Fibroid nodules, not exceeding the magni- 
tude of a pea, are sometimes found in the submucous tissue. Calcareous 
concretions, formed by the deposition of earthy matter in new-formed 
fibroid tissue, in obsolete tubercle, or desiccated pus, or fibrinous exuda- 
tion, occur very rarely. Rokitansky describes erectile groivths to exist 
in the intestinal canal, either in the form of sessile tumors, or pedicu- 
lated polypi. We are not sure whether he would include under this 
head instances of fibrous polypi, such as two recorded by Mr. P. Hewett, 
in the Report of the Pathological Society for 1846-47, which, though 
of marked fibrous structure, were livid in appearance, and pretty plenti- 
32 



498 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

fully supplied with bloodvessels. The presence of these polypi may 
give rise to invagination and its consequences. Tubercle selects the 
small and large intestines not unfrequently as its seat of deposit. It is 
met with more frequently in children than in adults, in the proportion 
of sixty-one to forty-three, and is more than twice as frequent in the 
small as in the large intestines. In the majority of cases the affection 
of the intestines is secondary to that of the lungs, and usually takes 
place after the tubercles in the latter have begun to suppurate, and the 
Cachexia has become fully developed. The course of intestinal tubercu- 
losis is "frequently chronic, but much oftener acute." The seat of the 
deposit is the submucous tissue, or the corium of the mucous membrane ; 
it is certainly subjacent to the basement-membrane, and not contained 
in the follicles, as Dr. Carswell taught. Rokitansky states that there 
is, in the chronic form, "no perceptible inflammatory action, and the 
disease appears in the shape of the gray transparent granulation, which 
softens at its centre, and is gradually converted from within outwards, 
into the yellow cheesy tubercle. It seems blended with the mucous 
membrane, and projects into the intestinal cavity in the shape of a 
sessile, hard nodule. Considerable inflammatory action attends upon 
acute tuberculosis. The exudation affects first Peyer'_s patches, then 
the solitary glands, and, lastly, every other part of the mucous tissue;" 
it appears in large masses, and in the shape of yellow cheesy matter, 
which speedily undergoes a purulent transformation. The surrounding 
tissue is extensively congested, reddened, and turgid, offering a good 
illustration of the influence of hyperemia in promoting tuberculous 
exudation. In the great majority of cases, as the tubercle softens, the 
mucous membrane over it gives way, and the suppurating mass escapes. 
In very rare cases this does not take place, but there is formed a small 
abscess in the submucous cellular tissue. The margin of the tubercular 
ulcer is firmly attached, rounded, and indurated ; its base, usually formed 
by condensed areolar tissue, may contain or not tuberculous matter. 
The enlargement of the ulcer in depth and in extent is effected by a 
process of essentially the same kind as is observed in cavities of the 
lung. The margin and the base become infiltrated with tuberculous 
exudation which softens and suppurates, and so the destructive process 
continually advances. Perforation of the intestinal wall sometimes 
occurs, the ulcer retaining throughout its original character, in which 
respect it differs from the typhous. The fatal event is often prevented 
by timely exudation of fibrin on the serous surface, which either thickens 
the wall or else unites it to an opposing surface. Mr. Ancell contests 
the statement that the tuberculous ulcer always retains its original cha- 
racter; he does not believe that ulcerations, the result of tuberculosis, 
are always produced by the deposit of tubercle. He views them as 
the result of "the ulcerous diathesis of the disease." Before this 
opinion can be accepted, microscopic evidence must be adduced to show 
that the base and margins are not the seat of tubercular infiltration, 
which Rokitansky affirms is the case. The mesenteric glands are en- 
larged by the special deposit, and often to considerable size. This, 
however, it may be stated, is not the essential circumstance in the dis- 
ease formerly called tabes mesenteriea. Tuberculous ulcers heal by a 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 499 

cessation of the morbid deposit taking place, and subsequent effusion of 
plastic fluid, which becomes organized into the cicatrix tissue before de- 
scribed. The contraction of this, if the ulcer has been of a large size, 
or extended round the intestine, may cause more or less contraction of 
its canal. Tuberculous disease generally, but not always, selects the 
lower part of the ileum as the seat of its chief ravages ; it oftener de- 
scends, we think, to the ccecum and colon than extends in the upward 
direction. 

Cancer not uncommonly attacks the intestinal canal; it is far more 
frequent in the large than in the small intestines; out of three hundred 
and seventy-eight fatal cases from this cause, in two hundred and twenty- 
one the disease was located in the rectum. All the three species occur 
in this situation, and colloid more frequently than in most others. Dr. 
Walshe seems to consider the small intestines to be more frequently 
affected than Rokitansky does; the latter says that "the colon is almost 
exclusively the seat of cancerous degeneration," while " the small intes- 
tine is scarcely ever the primary seat of cancer, except in the case of 
acute and extensive encephaloid disease. In the Report of the Patho- 
logical Society for 1847-48, there is recorded one case of cancer (colloid) 
of the small intestines and mesentery, and four of the ccecum, colon, 
and rectum. The duodenum and upper part of the jejunum are the parts 
of the small intestine most frequently affected, the rectum and sigmoid 
flexure those of the large which most frequently suffer. Rokitansky 
describes primary cancer of the intestines as occurring (1) as encephaloid 
infiltration of the submucous tissue and patches of Peyer ; (2) as carci- 
nomatous infiltration of erectile tissue ; (3) "more frequently in the 
submucous cellular tissue, as round nodulated accumulations; (4) most 
commonly as an annular deposit of the cancerous tissue in the submucous 
layer." Mr. Curling has met with an instance of epithelial cancer in 
the coats of the intestine. When the disease has its seat in the rectum, 
it most usually occurs at from two to three inches above the anus, 
according to Dr. Walshe, and tends to spread upwards rather than 
downwards. When the growth assumes an annular form, encircling the 
intestine, it produces gradually increasing constriction, which may ad- 
vance to such an extent that the canal is reduced to the diameter of a 
goose or even a crowquill. A tuberiform growth, occupying only one 
side of the intestine, also gives rise to considerable constriction; but 
this is not so great generally as in the former case. The narrowing 
of the passage, it is manifest, will be greatest while the growth remains 
in its original (crude) state ; but if, as not unfrequently happens, slough- 
ing and ulceration take place in the morbid mass, the obstructed passage 
will be again more or less reopened. In many cases, however, the ob- 
struction to the passage of the contents is such that the portion of the 
canal above the structure becomes immensely dilated, with its muscular 
tunic much hypertrophied, and its mucous, on the contrary, sometimes 
thinned, while that below contracts upon itself and becomes very small. 
Death often takes place in cases of intestinal cancer from the superven- 
tion of ileus and inflammation. The ileus (or anti-peristaltic action) is 
set up not only in consequence of the stricture preventing the passage 
of the contents of the bowel, for it may ensue when the canal is still 



500 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

tolerably pervious; but from the paralyzed condition of the walls of the 
intestine in the dilated and distended part, and from the masses of fecal 
matter which accumulate there. Inflammation attacks first the dilated 
part of intestine, " and is there most intense. This portion is discolored, 
of a dark blue or reddish aspect, its coats are infiltrated with blood ; 
the serous lining covered with exudation is easily detached, the muscular 
coat is discolored and friable ; the mucous membrane, owing to its dis- 
tension, is devoid of plicse, villi, or follicles ; dark red, distended at some 
parts with coagula, and sloughy." Sometimes perforation and its con- 
sequences take place. 

We shall lastly notice some morbid conditions of particular parts of 
the large intestine. The frequent occurrence of catarrhal inflammation 
in the coecum has been already mentioned ; but Rokitansky directs 
attention to a particular form which he terms Typhlitis stercoralis, 
indicating thereby its production by accumulation of indigestible and 
fecal matters in this situation. Sedentary habits and rheumatism of 
the muscular coat of the bowels are also stated to be causes of the dis- 
ease. We believe the proximate cause to be atony of the contractile 
fibres. "Removal of the accumulated pus, and avoidance of fresh 
accumulations, generally suffice to establish a cure. If this is not 
effected, ulcerative destruction of the mucous membrane, and continued 
sinuous suppuration of the muscular coat, result. In this manner, rapid 
perforation of the intestinal parietes, and especially of the posterior 
side, may follow, either inducing extensive inflammation, ichorous de- 
struction of the cellular tissue in the iliac and lumbar regions, and death; 
or giving rise to general peritonitis," from transmission of the inflamma- 
tion to the serous membrane. Inflammation sometimes attacks the lax 
cellular tissue which lies between the posterior surface of the coecum and 
the iliac fascia, and is apt to pass into suppuration. In many instances 
it is doubtless set up by pre-existing, perhaps chronic, inflammatory 
disease of the bowels ; but in others it occurs idiopathically, or meta- 
statically, as Rokitansky states. A calculus descending along the ureter 
has given rise to abscess in this situation. The purulent matter dif- 
fuses itself often for some considerable distance beneath the serous 
membrane ; it has been known to make its way up as high as the kidney, 
and as low as the interspace beneath the rectum and bladder. The 
abscess often opens into the coecum, and also externally. When the 
catarrhal affection of the coecum exists in a chronic form, it may cause 
the condensation of the surrounding cellular tissue, and shrivelling of 
the intestine itself, so that it " is found converted into a slate-colored 
capsule, with dense parietes, the size of a walnut or of a pigeon's egg." 
The cavity of the vermif. appendix often affords lodgement to indurated 
pellets of fecal matter, cherry-stones, or other such bodies, which cause 
irritation and inflammation, thickening of its coats, and subsequent 
ulceration. If the irritating substance can be got rid of, and the ulcer- 
ation ceases, the appendix shrivels up entirely, or in part, according to 
the extent of the mischief, assuming a lead or slate color. In two very 
interesting cases recorded together in the Report of the Pathological 
Society for 1847-48, the vermiform appendix protruded as a hernia, 
and had undergone ulceration in this situation. In the first, after an 



ABNORMAL CONDITION'S OF THE INTESTINAL CANAL. 501 

abscess and sinus had been laid open, a small piece of bone, of triangu- 
lar shape, and with sharp angles, was discharged, and recovery very 
quickly took place. Death occurring from a different cause not long 
after, it was found that the appendix vermif. was lying in the inguinal 
canal ; it was enlarged to three times its usual size, its coats much thick- 
ened, and its apex opaque, contracted, and adherent to the bottom of 
the canal. In the second case, there was a swelling of the scrotum 
caused by the hernial protrusion of omentum enveloping the appendix 
vermif. Abscesses and sinuses formed in the part, healthy pus was at 
first discharged, afterwards sanious and offensive matter ; the quantity 
of discharge was profuse, but varied in quantity, and was frequently of 
a pale orange color. Death occurred from exhaustion, and it was found 
that the appendix, healthy in structure all the way down to near its 
blind extremity, was ulcerated at about half an inch from this point, 
and that a communication existed between its interior and the sinuses 
of the scrotum. More often inflammation, excited in the vermiform 
appendix by the presence of hard bodies, extends to the peritoneum, 
and either at once induces general peritonitis, or gives rise to adhesions, 
which even if gangrene of the part and perforation occur, may prevent 
the fatal result for some time. Rokitansky mentions, a curious accident 
of a different kind which sometimes befalls the appendix. Its canal 
gets blocked up at a certain part by a foreign body without ulceration 
taking place. In consequence of this, the mucous secretion accumulates 
in the closed receptacle, which it distends into a kind of dropsical pouch 
lined by a thin, serous-like membrane. 

The defective state of development of the rectum already alluded to 
as atresia ani is of various degrees, consisting either in simple closure 
of the anus by the integument being continued across it, or in the rec- 
tum terminating in a blind pouch at a greater or less distance from the 
anus. Sometimes the canal extends for an inch or two upwards from 
the anus, and then terminates. It is important to remark that when 
the deficiency in the rectum is considerable, the pelvis is also imperfectly 
developed, especially in its antero-posterior diameter. 

Lacerations of the rectum and anus occasionally take place, all the 
coats sometimes being torn through, as after a severe labor when the 
perineum has quite given way, or only the mucous lining being injured, 
as sometimes happens after the passage of concretions, or hardened 
feces. The rectum may be excessively distended by fecal accumula- 
tions, especially in persons of lax fibre and low nervous power, or when 
paraplegia exists. Sometimes its channel is much narrowed by the 
pressure of surrounding organs, when displaced or diseased ; a retro- 
verted uterus, an enlarged prostate, a vesical calculus, or a pessary in 
the vagina, may all have this effect. Rokitansky asserts that hyper- 
trophy of the sphincter ani may give rise to obstinate constipation, and 
even to ileus, and that it frequently induces excoriation of the mucous 
membrane, the so-called fissure Of the rectum. We think the converse 
is generally, if not always, the case, that excoriation or cracking of the 
mucous membrane, by the irritation which it excites, becomes the cause 
of excessive action and consequent hypertrophy of the sphincter. This 
is the opinion also of Sir B. Brodie, who says that "the contraction of 



bOX ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

the sphincter appears at first merely spasmodic ; but in proportion as 
this muscle is called into action it increases in bulk ; and after the 
affection has continued for some time, it becomes considerably larger." 
Fissures may be situated at various points, as described by Dupuytren ; 
some, which are below the sphincter, and scarcely involve any texture 
but the skin, occasion only pruritus. Those which are above the sphinc- 
ter give to the finger the sensation of a knotty hard cord, and during 
the act of defecation give rise to indescribable tenesmus. They are 
commonly produced by the ulceration of internal piles, and mark their 
situation on the cylinder of feces by a streak of puriform, sometimes 
bloody mucus. Fissures situated on a level with the sphincter are the 
worst, being attended with such agonizing pain during defecation, that 
patients have been known nearly to starve themselves to avoid the re- 
currence of the action as much as possible. The appearance of these 
ulcers is that of a narrow fissure, " the bottom of which is red, and the 
margin somewhat swollen and callous." "Catarrh and blennorrhcea," 
says Rokitansky, " accompanied by hypertrophy of the coats, which 
frequently gives rise to plicated and polypous excrescences of the mucous 
membrane, are very frequent affections of the rectum." Dr. Copland 
describes rectal polypi as varying from the size of a pea to that of an egg, 
having a broad or a very narrow pedicle, situated high up or low down, 
presenting generally a mucous aspect, a pale-reddish hue, and a smooth 
or lobulated surface. A small growth of this kind, which we had the 
opportunity of examining through the kindness of Mr. I. B. Brown, 
had a short pedicle, was of the size of a pea, rather highly vascular, of 
lobulated aspect. It consisted entirely of Lieberkiihn follicles, and of 




Piles, after excision, showing the dilated veins, of which they are in a great measure composed. 

low folds or ridges covered with well-marked columnar epithelium, and 
mingled with only a small quantity of fibroid tissue. Hemorrhoids de- 
pend essentially on a dilated condition of the veins of the rectal mucous 
membrane, and are quite analogous to the varices of the legs, which 
are so common. They are named internal, or external, according as 
they are situated above or below the sphincter. Although all take 
their origin in dilatation of the hsemorrhoidal veins, yet in their subse- 
quent progress they come to present different appearances, which we 
proceed to notice. The first variety, sometimes termed mariscse, are 
described by Dr. Copland as " fleshy tubercles, of a brownish or pale- 
red color, situate within the anus, or descending from the rectum. 
They have a somewhat solid or spongy feel ; and when divided they pre- 
sent a compact, or porous and bloody surface. As the blood oozes from 
the cut surfaces, they become pale and flaccid." Whether internal or ex- 
ternal, they often contain a central cavity filled with fluid, or coagu- 
lated blood, of a dark color. " More frequently, there is no regular 



ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 503 

cavity, the substance of the tumor being as if infiltrated with blood, 
-which becomes coagulated and dark ; but this appearance is not owing 
to extravasation, but rather to a dilatation of a number of small vessels 
which traverse the tissue in the direction of the axis of the rectum ; as, 
upon dividing the part longitudinally, numerous dark streaks are seen 
in its substance, while a section made transversely shows only small 
roundish specks." These tumors elongate, assuming a conical form 
with bases larger than their necks. Sometimes blood is exhaled from 
their surface, sometimes only a serous fluid, and sometimes, when they 
are external, they are quite dry. At first, they generally disappear in 
two, three, or four days ; but return again at an uncertain, or at a regu- 
lar period, and increase in size, becoming firmer in texture. " After 
some blood is evacuated from them, or after the determination of 
blood to the parts has ceased, they collapse, leaving small pendulous 
flaps of skin, which ultimately disappear if the tumors have been 
small ; but if they have been large, these flaps continue conspicuous, 
and give a projecting and irregular margin to the anus." Having 
been strangulated by the sphincter, or repeatedly engorged with blood, 
or chronically inflamed, these tumors become more permanent and solid. 
" The permanent state of the tumors is owing partly to the development 
of capillary vessels, and partly to the effused blood and lymph becoming 
organized; this latter circumstance especially giving rise to the excres- 
cences, or irregular mass of tumors found around the anus in those sub- 
ject to haemorrhoids." The second variety of hemorrhoidal tumors 
includes such as are formed by a pure dilatation, or varicose state 
of the veins of the part. Dr. Copland, from whom we continue to 
quote, describes them " as not so disposed to enlarge at particular 
periods, and as more permanent, and less painful, than" the first 
variety. " They are commonly of a dark or bluish color, and soft 
and elastic to the touch." They are easily emptied by compression, 
but quickly fill again. " They are round and broad at the base, 
and often distributed in irregular or ill-defined clusters," which ex- 
tend often for some way up the rectum, sometimes even as far as the 
colon. " M. Begin observes that, in most cases, the dilated, superficial, 
submucous, or subcutaneous veins are only the smaller part of those 

Fig. 226. 




A slightly lobulated tumor divided in its middle, and the cut surfaces exposed. It was passed per anum. 
It seems to have been formed by exudation taking place around varicose dilatations of the veins. The cavi- 
ties seem to have resulted from the dilatation of mucous follicles. 

surrounding the rectum. Sometimes the lower part of this intestine 
appears as if plunged in the middle of a network of dilated and engorged 
veins, forming a thick vascular ring, the incision or puncture of which 
may give rise to dangerous hemorrhages." If, in consequence of in- 



504 ABNORMAL CONDITIONS OF THE INTESTINAL CANAL. 

flammation on the congestion of the varicose vessels, exudations of 
plastic matter take place around or in the substance of these tumors, 
they become more solid, and more or less similar to those of the first 
variety. Sometimes the products of inflammation are deposited within 
the dilated vessel, which induces its obliteration, and the atrophy of the 
tumor. Perhaps in some cases the reverse takes place, a vein within 
an originally solid tumor may become considerably dilated. In short, 
the varieties met with seem chiefly to depend on the predominance of 
vascular dilatation, or surrounding plastic exudation. A third variety 
of hemorrhoidal tumors are described as of an erectile character. They 
are soft and spongy, and of a purplish color, and give rise to considera- 
ble losses of blood. Dr. Colles found in one case " bloodvessels of the 
size of crowquills, running for some way down the intestine, then 
dividing each into numerous ramifications, and each forming, by the in- 
terlacing of its numerous branches, one of these erectile or vascular 
tumors. The trunks and branches of these vessels were covered only 
by the lining membrane of the intestine." Some hemorrhoidal tumors 
appear to result from the effusion and coagulation of blood in the sur- 
rounding tissue. The reality of this occurrence is denied by Rokitan- 
sky, but we quite acquiesce in the remarks of Mr. H. Lee, 1 that it is by 
no means easy to determine whether the delicate, smooth, and shining 
membrane lining the cavities in which the coagula are contained, is the 
lining membrane of the venous system, or one of new formation derived 
from the blood itself. He also notices the effect of hemorrhoidal tumors 
on the mucous membrane around them, which is raised and forced down 
along with them when they are protruded beyond the sphincter, so that 
at last it becomes permanently relaxed and "baggy.'' The female sex, 
sedentary occupations, and constipation, are enumerated as the chief 
cause of haemorrhoids, to which we should add a plethoric habit, and a 
lax condition of fibre. It does not appear at all proved that cirrhosis 
of the liver, or obstructive disease of the heart, has any marked influ- 
ence in the production of piles, as one would naturally expect. The 
mucous membrane thinned over an hemorrhoidal tumor is prone to 
ulcerate, and the resulting sore, according to Rokitansky, is character- 
ized by its seat in the vicinity of the sphincters, its irregular shape, its 
indented and sinuous flabby margin of mucous membrane, and the 
ridges of similar tissue that surround or pass over it. These ulcers 
may continue to burrow into the surrounding areolar tissue, and give 
rise there to abscess, and ultimately to fistula in ano. This, however, 
more often results from inflammation being set up in the deeper-seated 
tissues, the areolar and adipose, but still in the vicinity of the bowel, 
which advances to suppuration, and in most cases makes its way first 
outwardly through the integument surrounding the anus, and afterwards 
establishes a communication with the cavity of the rectum by a small 
aperture situated very constantly at the distance of an inch, or an inch 
and a quarter, from the anus. It does not clearly appear why fistula 
in ano should occur so often as it does in persons prone to pulmonary 
tuberculosis, and still less why its existence should be preservative, at 

1 Medical Gazette, August, 1848. 



ABNORMAL CONDITIONS OF THE INTESTINAL CONTENTS. 505 

least in not a few cases, against the invasion of the dread malady. 
Cancerous disease attacks the rectum in most of the forms mentioned as 
aifecting the whole intestine; the only one which it seems desirable 
especially to notice, is that which gives rise to the annular structure. 
This occurs almost exclusively at the upper portion of the rectum, espe- 
cially at the junction of the sigmoid flexure; the strictured part is 
sometimes unattached, more often firmly agglutinated to the promontory 
of the sacrum, but is, nevertheless, pushed down by the feculent accu- 
mulations above, so as to be within reach of examination by the finger. 



VII. ABNORMAL CONDITIONS OF THE INTESTINAL 
CONTENTS. 

The secretion of an excessive quantity of gas from the lining mem- 
brane of the intestinal canal constitutes the most ordinary form of 
Tympanitis. It often occurs in inflammatory affections of the canal, 
which induce more or less paralysis of the coats, in consequence of which 
the gas is not expelled, but goes on accumulating. The gas in the 
stomach of an executed criminal was found by Magendie and Chevreul 
to consist of atmospheric air with a part of its oxygen replaced by car- 
bonic acid, and some hydrogen. In cancerous strictures of the pylorus, 
and in chronic catarrhal states, the gas contains but little oxygen, much 
carbonic acid, probably also hydrogen, and carburetted hydrogen, and 
constantly also sulphuretted hydrogen. In the small intestines of 
criminals, Magendie and Chevreul found an abundance of hydrogen and 
carbonic acid, no oxygen, and a varying quantity of nitrogen. Mar- 
chand found in the gaseous contents of the large intestines carbonic 
acid, nitrogen, hydrogen, carburetted hydrogen, and a small proportion 
in one case of sulphuretted hydrogen. That these gases are secreted 
by the mucous lining, and do not proceed from decomposition of the 
ingesta, is considered improbable by Lehmann. We cannot, however, 
coincide in his opinion, at least to the exclusion of the first-mentioned 
way of production, if for no other reasons, on account of the experi- 
ment performed by Frerichs, which he himself details, that a portion of 
intestine emptied of its contents, and isolated from the rest of the canal 
by two ligatures, always became full of gas after being left some time. 
Mucus in any appreciable quantity can scarcely be said to exist in per- 
fectly healthy intestines ; but it is secreted abundantly, as we have seen, 
under catarrhal irritation. Rokitansky applies to it the following 
epithets in various cases; it is either milky white, yellowish, and puru- 
lent, or glutinous, transparent, vitreous, spawny. He also states "that 
there can be no doubt that a peculiar gelatinous constitution of the 
mucus is the nidus of intestinal entozoa, and the cause of helminthiasis. " 
Under irritation of an acute character small membranous patches of 
mucus are often passed; we have seen these in a case of dysentery con- 
stituting the whole of the scanty evacuation. Between these and the 
fibrinous tubular formation before noticed, there is no very essential 
difference, and both are to be distinguished from certain membranous 
substances which occasionally appear in the evacuations, and may cause 



OUb ABNORMAL CONDITIONS OF THE INTESTINAL CONTENTS. 

some perplexity to the patient and physician, unless their nature be 
understood. These are simply the undigested remains of some tendin- 
ous expansions, -which contain a great deal of yellow elastic fibre, on 
which the gastric juice seems to act with much less energy than on the 
•white. Rokitansky says that "the occurrence of an excessive elimina- 
tion of feces from the intestinal secretions is an established fact. It 
takes place as a critical discharge in various diseases," but may also 
occur as an idiopathic affection, " which may, by the excessive drain it 
causes, give rise to atrophy of the intestinal coats, and to general emaci- 
ation. 

Concretions are occasionally met with in the intestinal canal, and in 
rare instances of very large size. Dr. Monro (Primus) observed some 
varying from five to eight inches in circumference, and Monro (Secundus) 
removed one from the colon which weighed four pounds. Sometimes 
several, as many as thirty, exist together, but commonly there are not 
more than two. The color of the smaller resembles that of iron ochre, 
the larger are more of a coffee color, and occasionally whitish. " They 
are generally found in concentric layers, and are often radiated, some- 
times very obscurely from nuclei. They are more or less porous, either 
spheroidal or oblong, and vary from the size of a pea to that of a hen's 
egg, or still larger." The nuclei of concretions may be gall-stones, 
fragments of bones, fruit, seed, &c, round which saline and animal or 
undigested matters collect and become condensed. In Scotland, where 
oatmeal is much used as an article of food, the fibres of the husk of the 
oats have been found to constitute a large part, or nearly the whole of 
the concretion ; and in a similar manner, chewed paper, the several por- 
tions being matted together by mucus with fecal and earthy matter, has 
been known to cause their formation. Such concretions often exhibit 
no distinct nucleus. Concretions, which may be mistaken for gall-stones, 
but which are of a fatty nature, are sometimes voided by persons who 
suffer from a torpid state of the bowels, and deficient digestive function. 
Dr. Copland describes them as of a globular form, varying from the size 
of a pea to that of a large grape, of a cream color, slightly translucent, 
and of the consistence of soft wax. It is probable that these concre- 
tions, as well as the evacuations of a more fluid fat which occasionally 
take place, are connected in some measure with disease of the pancreas. 
Observation of disease has in several instances shown the coincidence 
of the two phenomena; and Bernard has offered a physiological explana- 
tion, viz: that the use of the pancreatic secretion is to make the fat 
contained in the food capable of being absorbed. His results, however, 
are denied by Frerichs, Bidder, and Schmidt. Blood is sometimes 
effused in greater or smaller quantities into the intestinal canal. This 
may result from active or passive hypersemia, ulcerations, purpura, scor- 
butic dysentery, and we have once seen it in a case of death from a 
Bevere fall. 



CHAPTER XXXIII. 

ABNORMAL CONDITIONS OF THE LIVER. 

Congenital malformations are rare ; absence of the liver is only ob- 
served in extreme cases. Sometimes the left lobe retains, in a greater 
or less degree, its foetal proportion to the right. 

Congestion. The vascular apparatus of the liver is very large, its 
capillaries are more capacious than those of most other parts, and the 
caliber of the portal, and especially of the hepatic veins is extremely 
ample. It is, therefore, capable of containing a very large quantity of 
blood. Though its surface is closely invested by its capsule, yet this 
membrane allows of a good deal of distension, and this is also attested 
by the tortuosities of the arterioles of the surface, which probably exist 
for the purpose of allowing the vessels to be elongated without injury 
to their texture. Congestion of the liver may be general or partial. 
The latter is far the more common condition, and, indeed, in its lower 
degrees is not morbid. The central parts of the lobules, in perfectly 
healthy livers, are often seen to be marked by a spot of redness which 
occupies about the middle two-fourths of the whole diameter. This is 
produced by the blood, as the circulation gradually failed, having stag- 
nated in the hepatic veins, in their radicles, the intra-lobular veins, and 
the surrounding capillaries. Mr. Kiernan named this, " Hepatic Venous 
Congestion of the first degree." When the congestion extends further 
in the direction backwards, there are seen no longer mere spots of red- 
ness, but patches of very irregular shape surrounding, more or less 
completely, portions that are not congested. These portions are situated 
at the interlobular spaces, where three or more lobules adjoin. Such a 
condition was named by Mr. Kiernan, "Hepatic Venous Congestion of 
the second degree." This may coexist with a perfectly healthy condition 
of the cells which occupy the meshes of the capillary plexus, but not 
unfrequently these are variously altered, and thus give rise to some 
modification of the appearance. 

The "nutmeg" condition may be here referred to; it consists, in its 
best-marked instances, of deep red congestion, forming patches and 
streaks, occupying the central parts of the lobules, and surrounded by 
patches of a grayish, or dirty white color. The congested portions are 
most definitely limited, and the contrast between them and the pale parts 
is extremely striking. This probably depends on the circumstance that 
the portions thus devoid of blood are affected with fatty degeneration, 
a change which, by causing the cells to increase in bulk, occasions com- 
pression of the interwoven capillaries. That this is the true cause of 



508 



ABNORMAL CONDITIONS OF THE LIVER. 



the limitation of the congestion is proved by its exactly ceasing at the 
inner margin of the zone of fatty degeneration. Many of the cells in 
the congested part are seen filled with dark yellow matter; very many, 



Fig. 227. 




Section of liver, showing the nutmeg appearance ; the dark parts are the deep red congested central parts of 

the lobules. 

also, are atrophied, probably in consequence of the pressure exerted by 
the distended capillaries. The nutmeg appearance may be exhibited in 
some degree, by livers which are quite free from fatty degeneration, but 
it is never so marked as in the condition just described. 

When the congestion extends still further and becomes general, occu- 
pying every part of the liver, the organ presents a deep red color 

Fig. 228. 








(a) Section showing lobules of the liver, bounded by marginal zones in a state of fatty degeneration. The 
interior of the lobules is deeply congested, and contains much dark yellow pigment in masses. 

(b) Cells loaded with pigment, atrophied cells and granular matter from the interior of the lobules. 

throughout, though, even in this case, the centres of the lobules present 
the darkest tint ; it is also enlarged often to a greatly increased size, 



ABNORMAL CONDITIONS OF THE LIVER. 509 

and becomes more firm and prominent, so as to be readily perceptible 
to the touch, below the margin of the ribs, on the right side. The result 
of injecting a liver which is nearly drained of its blood, as one taken 
from a slaughtered sheep, is very instructive as to the amount of en- 
largement that may be produced by congestion. The organ swells up 
as the fluid is thrown in, and when fully injected, is of nearly double its 
former size, greatly more dense and solid, with its thin anterior margin 
prominent and hard. Such a state may well produce a sense of weight 
and fulness in the right hypochondrium. 

The most frequent cause of congestion to any degree that can be con- 
sidered morbid is organic disease of the heart, especially such as produces 
great obstruction to the circulation, and throws the blood back upon the 
right side of the heart, and the venous system in general. All causes 
of apncea produce the same effect, and act in the same way. Congestion 
thus induced is passive ; active congestion takes place in inflammation 
of the liver, or, as we have observed, when large doses of calomel are 
administered. The congestion which occurs in the cold stage of ague 
and other fevers, seems to depend simply on the recession of the blood 
from the surface, and is, therefore, more of the nature of passive than 
of active. 

Portal venous congestion is a rare variety of partial ; the centres of 
the lobules are pale, and are surrounded by continuous red zones. It is 
said to occur in children only. 

Congestion of the liver, although extreme, does not seem to occasion 
any structural change, if it is only temporary; but if, as in the case of 
obstructive cardiac disease, it results from a permanent cause, and is, 
consequently, itself permanent, it produces the following effects : The 
distended capillaries of the portal-hepatic plexus, press on the intervening 
cells; these become, in part, atrophied or stunted, in extreme cases almost 
destroyed : in part, they are gorged with yellow matter to such a degree 
that they appear as opaque masses. The quantity of yellow matter thus 
formed is far greater than any that exists in healthy states of the organ, 
and, as some of it is doubtless absorbed and carried into the blood, we 
find in this circumstance some explanation of the icteric hue which is so 
often observed in such patients. The connection^hich certainly exists 
between the congestion and the yellow engorgement of the cells, as cause 
and effect, gives additional support to the opinion that the yellow bile- 
pigment is a modification of, and derived from, the coloring matter of 
the blood. Whether long-continued congestion produces still further 
changes, is not yet made out clearly. We have often thought that the 
lobular parenchyma was infiltrated by a dense, homogeneous, solidified 
blastema, distinct from the debris of the atrophied cells, but this may 
have resulted from a different cause. 

Hemorrhagic effusion may take place as the result of extreme con- 
gestion, but this is rare; the blood may be poured out either on the 
surface, detaching the capsule for some extent, or deeper in the sub- 
stance of the organ. The former occurrence, Rokitansky states, is most 
common in infants, and may even proceed to such an extent as to rupture 
the serous investment, and allow the escape of blood into the peritoneal 
cavity. The deep-seated extravasations occur more frequently in adults 



510 ABNORMAL CONDITIONS OF THE LIVER. 

than the superficial, and constitute apoplectic spots of various forms and 
size. After their partial absorption, a cellulo-fibrous cicatrix remains. 
Inflammation of the liver must be considered as affecting either the 
substance of the organ, chiefly, or its capsule. The former is, in tem- 
perate climates, a rather rare affection, the latter extremely common. 
Acute inflammation of the parenchyma of the liver produces general 
congestion and more or less softening. "These effects," Rokitansky 
says, "are confined to one or more patches; the congestion, though 
general, is not universal. The viscus is swollen in proportion to the 
number and size of the inflammatory patches, and this tumefaction is 
particularly perceptible when a section is made, the turgid tissue rising 
above the edges of the incision and the peritoneal sheath." The paren- 
chyma "is loosened and lacerable;" this depends in great part on the 
cells losing their natural cohesion together, so that they no longer form 
radiating series. In the latter stages of inflammation, the red color of 
active congestion fades, and is replaced by a brownish or grayish-red 
tint in some parts, with yellowish-red or pale-yellow in others. Abscess 
is a frequent result of acute inflammation of the liver : it is sometimes 
preceded by a short stage of diffuse suppuration, when the form of the 
lobules can still be recognized, though their substance is very soft and 
of a yellowish color. The commencing abscesses are at first very small, 
like spots of purulent matter dispersed here and there through the in- 
flamed and softened tissue ; they gradually enlarge, several coalesce 
together, and thus form cavities of irregular shape and size. The pa- 
rietes of the abscess are uneven, presenting the remains of former par- 
titions ; they are covered by a kind of pyogenic membrane, which consists, 
in great part, of pus-globules; external to this, the wall is formed by 
hepatic tissue, infiltrated with exudation-matter, which serves to bound 
and limit the abscess, as in the case of a common phlegmon. In very 
small abscesses, and those of very recent formation, as also in cases 
where the vital powers are greatly depressed, this limitation of the 
abscess by exudation-substance does not take place ; on the other hand, 
in old abscesses, and those of very large size, occurring in tolerably 
healthy systems, a strong enveloping cyst may be found, consisting of 
fibroid tissue, and an#unting sometimes to three or four lines in thick- 
ness. If the abscess be deep-seated and encysted, it may continue, 
especially if of small size, for a long time, without increasing much, or 
producing serious disturbance of the health ; but, if it be near the sur- 
face, it excites inflammation of the serous investment, and effusion of 
lymph, which soon unites its wall with the part with which it is in contact. 
This may be the wall of the abdomen, or some of its contained hollow 
viscera, or the diaphragm which roofs it in above ; and by any of these 
various routes the abscess may extend, and at length discharge its con- 
tents. By extension, also, in the parenchyma of the liver, the abscess 
may reach a branch of the portal vein or of the hepatic, excite inflam- 
mation of its coats, and consequent obstruction of its canal by exuded 
fibrin. When the enlarging abscess reaches an hepatic duct-branch, it 
affects it in a different way; it does not set up inflammation in its walls, 
and cause its obstruction (though this may no doubt occur in some of 
the smaller), but it ulcerates through its tunic, and establishes a comniu- 



ABNORMAL CONDITIONS OF THE LIVER. 511 

niantion between the efferent channel and its own cavity. Hence, it 
occurs that the pus contained in large abscesses is always mingled with 
a considerable quantity of bile, while that of the smaller and recent 
abscess is almost pure. An abscess of the liver may sometimes heal 
either after the evacuation of its contents, or after they have been 
absorbed; the latter occurrence is, we should conceive, exceedingly rare. 
In either case, the walls of the abscess approach each other, and at last 
collapse together, including sometimes a quantity of solidified purulent 
matter, which at a later period forms a cheesy or cretaceous mass, 
attesting, by its presence in the midst of the cicatrix, the nature of the 
changes which had previously taken place. 

Several different causes have been assigned for the formation of 
abscess in the liver, but none are probably nearly so effective as that 
to which Dr. Budd has especially drawn attention. Dysenteric ulcera- 
tion, or any accident producing inflammation of the veins that originate 
the V. Portse, charges the current of blood proceeding to that organ 
with puriform matter, which, in its passage through the capillaries of 
the lobules sets up secondary inflammation, attended with albuminous 
exudation, and terminating quickly in the formation of matter. It is 
not clearly made out in what way injuries of the brain act in producing 
abscess of the liver ; but it is probably in the same way, though by a 
less direct channel than that just described ; so, also, many regard the 
occurrence of the so-called secondary depots in the liver, subsequent to 
amputations, and other great operations, as the result of phlebitis at- 
tacking the veins of the injured part. The only other causes which 
can be named with any certainty as producing abscess are, external 
violence inflicted on the region of the liver, and violent acute inflam- 
mation of the organ, such as occurs in tropical climates. It is worthy 
of remark, that typhoid and tuberculous ulcerations of the intestines, 
as well as those consequent on burns, do not, at least, have not yet been 
observed to, produce abscess of the liver. 

The capsule of the liver is very often indeed attacked with inflamma- 
tion, or presents, on post-mortem examination, such changes as are 
usually ascribed to this process. Bands of adhesion of various length, 
and attaching different parts of its surface to contiguous organs, are 
very often found : these are pretty certain evidences of an acute or 
subacute by-past hepatitis ; they are often traversed by newly-formed 
vessels which establish a communication between the capsular arterioles 
and the contiguous vessels of the general system. In a specimen which 
we injected, the vessels of a patch of false membrane, on the surface 
of the capsule, are seen to be of much greater caliber than the vessels 
in the adjacent healthy part. Adhesions commonly form, as said, over 
superficial abscesses of the liver : it is rare that this fails to take place, 
and that an abscess bursts into the peritoneum. Over hydatid tumors 
and cancerous masses they are less frequently formed. Dr. Budd par- 
ticularly notices their absence, and considers that their production is the 
exception and not the rule. This may, perhaps, be in some measure 
accounted for by another circumstance relative to cancerous tumors in 
this organ, mentioned by the same observer, viz : that they seem capable 
of tainting, with their own peculiar morbid action, opposed parts with 



512 ABNORMAL CONDITIONS OF THE LIVER. 

which they come in contact ; such tainting of a part may be conceited 
to be quite inconsistent with the effusion of comparatively healthy lymph. 
The capsule of the liver is very frequently found thickened, appearing 
whiter, more opaque, and dense ; this thickening generally occurs in 
patches of various size, which sometimes coexist together with the bands 
of adhesion just noticed, but quite as often are independent of them, or 
coincident with similar thickenings of other serous membranes. It seems 
doubtful whether these changes should not be more properly classed as 
degenerations than as inflammations. 

G-angrene of the liver is very rare ; Rokitansky well observes that 
" it is developed in parts affected with inflammation and suppuration, 
not so much as a result of intense inflammation as of certain peculiar 
conditions which cause a tendency to gangrenous degeneration." These 
peculiar conditions may be probably either low, unhealthy states of the 
general system, or, as in the interesting case recorded by Dr. Budd, the 
septic influence of a previously healthy part which had been affected by 
gangrene. 

Phlebitis of the portal or hepatic vein-branches has already been 
alluded to as resulting occasionally from abscess of the liver, but it may 
be produced by other causes. A fish-bone has been known to perforate 
the wall of the stomach and the head of the pancreas, and wound the 
superior mesenteric vein, exciting thus inflammation of the coats of the 
vessel which extended to the divisions of the portal vein. The effects 
of phlebitis are the same in these as in other veins; it may simply occa- 
sion the effusion of lymph and blocking up of the channel with fibrinous 
coagula, or it may also proceed in some portions of the vein to the form- 
ation of pus. 1 In the former case, when the inflammation has subsided, 
the obstructed vessel gradually shrinks, and is reduced to a fibrous cord, 
while the surrounding tissue to which it was distributed, being deprived 
of its supply of blood, atrophies and falls in, so that the course of the 
vein is indicated by a deep linear fissure. If suppuration occurs, a string 
of small abscesses is produced in the tract of the obliterated vein, the 
abscesses being connected together by a dense fibroid cord. The con- 
sequence of such attacks must be the diminution, to a greater or less 
extent, of efficient hepatic parenchyma, and as the importance of this 
structure to the due performance of nutritive absorption is very manifest 
(were it attested only by the intimate relation in which it is placed with 
the portal blood), it seems very probable that the abiding emaciated and 
enfeebled condition of many persons who have suffered inflammatory 
attacks of the liver, really depends on their having been thus deprived 
of a greater or less part of this important organ. 

Cirrhosis. — A liver which is affected by this change in an extreme 
degree is remarkably altered. It is much smaller than natural, much 

1 In a case occurring at St. Mary's Hospital, all the portal veins throughout the liver, 
up to those of a very small size, were converted into channels with ragged walls filled with 
a tenacious pus. Here and there the vein-channel was enlarged into an irregular pouch, 
but there were no distinct abscesses. The cause of the phlebitis appeared to have been 
a patch of ragged ulceration at the origin of the portal vein. The parenchyma was not 
atrophied. The hepatic ducts were not inflamed, but the gall-bladder and duodenum ap- 
peared so. 



ABNORMAL CONDITIONS OF THE LIVER. 



513 



paler, and instead of presenting a smooth surface, is contracted and 
puckered so as to resemble, according to a former observer, " a conge- 
Fig. 229. 




Section of liver in a fatty state, with abundant new-formed fibrous tissue between the lobules. 

ries of little firm globules like the vitellarium of a laying hen." These 
globular portions are of various sizes, and evidently consist of paren- 
chymatous substance ; they are surrounded, and as it were capsulated 
by firm fibroid tissue which extends throughout the whole liver, and 
gives it a remarkable degree of density and firmness. This fibroid tissue 
is evidently a new formation, and as such tissue frequently does, it con- 
tracts and shrinks together, and so draws in the surface at various parts 
as to produce the irregular nodulated, or "hobnail" condition, as it is 
familiarly termed. The same shrinking also affects the vessels which 
supply the liver ; they are surrounded and ensheathed by fibrous tissue 
in the healthy state, and when this is morbidly thickened and condensed, 
the pressure exerted upon them narrows their channels and materially 
diminishes the quantity of blood which they are able to convey. Hence 
the portal current is checked at its very origin, and the congested capil- 
laries are obliged to relieve themselves by effusion of serum into the 
peritoneal cavity. The capsule of a cirrhotic liver is sometimes smooth, 
sometimes thickened or attached by adhesions to adjacent parts ; these 
adhesions are often traversed by newly-formed vessels, which form a 
kind of collateral circulation between the portal vein and the general 
system. 

Such is a brief description of a liver affected with ordinary cirrhosis ; 
but there are other conditions of the organ, essentially similar, in which 
the external appearances are very different. The organ is firm and 
dense, evidently from the presence of an increased quantity of fibroid 
tissue ; but its surface is not puckered, or but slightly, nor its edges 
rounded ; instead of being pale, it may be highly congested with blood, 
usually of the hepatic venous second degree, this often depending on 
obstructive cardiac disease. Microscopic examination shows that the 
quantity of fibroid tissue forming the Glissonian sheaths is considerably 
increased, sometimes to such a degree as to encroach on the lobules to 
33 



514 ABNORMAL CONDITIONS OF THE LIVER. 

a great extent, and produce atrophy of their substance. It is possible 
that some livers which present these appearances may be fn an early 
stage of cirrhosis, and would subsequently become contracted and nodu- 
lated ; but we strongly incline to the belief that this is not the case 




Fibres originating from nuclei from fibrous tissue of a cirrhotic liver. Some cells are figured of the natural 
size, others are very much atrophied. 

with the majority, and that the morbid alteration is somewhat different. 
The difference probably consists in the more general and extensive 
formation of fibroid tissue throughout the liver, in its being less confined 
to the portal canals. It is rather remarkable that the hepatic cells in 
extremely contracted cirrhotic livers present a tolerably healthy aspect ; 
their nuclei are distinct, and though, perhaps, containing less oil than 
usual, they are by no means destroyed or seriously altered. They are 
far more affected in the dense, firm, uncontracted livers, partly as the 
result of congestion with impletion of yellow matter, partly by atrophy 
from the encroaching fibroid tissue. The minute ducts which run in 
the smaller portal canals and between the lobules are often atrophied 
by the pressure of the condensed fibrous tissues, so that they can no 
longer be detected; in this way the biliary secretion may be materially 
interfered with. 

It seems to be proved by the observations of Dr. Bright and Dr. 
Budd that in the early stage of cirrhosis the liver is enlarged ; this 
would seem to»depend on the effusion of lymph and serum within its 
texture during the existence of inflammatory action. In many cases 
there can be little doubt that this is the case, and that the cirrhotic 
change results from a subacute inflammatory action being set up in the 
Glissonian sheaths. But in many cases we are disposed to think the 
process is different; that, both in the finally contracted and uncontracted 
livers, the fibrous tissue is hypertrophied and condensed rather by a 
degenerative action than by one which can be termed inflammatory. 
The change seems to be of a similar kind to that which produces carti- 
laginoid induration of the capsule of the spleen, stiffening of the valves 
of the heart and contraction of its orifices, which can scarcely be re- 
garded as of inflammatory origin. We are confirmed in this view by 
having often observed various minor degrees of condensation and thick- 
ening of the Glissonian sheaths in cases where there was no trace of 
inflammatory action, as well as by a circumstance which hitherto has 
been quite unexplained. This is, that the spleen, albeit exposed to the 



ABNORMAL CONDITIONS OF THE LIVER. 515 

backward pressure of the blood retarded in the splenic vein, does not 
become distended in the way that one would expect, but is often, on the 
contrary, small and soft. In such spleens, we have often observed very 
many of the nuclei throwing out fibres, which is certainly not their 
natural metamorphosis ; and hence it seems not improbable that in this 
way, owing to the increase of fibrous tissue in its substance, the paren- 
chyma of the spleen is less distensible than usual, and has a contrary 
tendency to shrink and collapse. 

The remote cause of cirrhosis, in many cases, is certainly the habit 
of spirit-drinking: the alcohol absorbed into the portal blood first passes 
through the liver, and very probably exerts some action on its tissue. 
This suggests the idea of the spirit acting as a local irritant, and with 
this Dr. Percy's observation of the greater affinity of alcohol for the 
liver than for other organs in animals poisoned by it seems to harmon- 
ize. But it is most probable that the crasis of the blood is also changed, 
and that this fluid comes to be in that condition which Rokitansky de- 
nominates the fibrinous crasis. This would also account for the similar 
changes which are often found in other parts coexisting with cirrhosis. 
Obstructive cardiac disease is probably not a direct cause of cirrhosis 
in any of its forms or degrees, but certainly must be a predisposing one. 
Congestion favors the occurrence both of inflammation and of degenera- 
tion. Both the heart disease (e. g. constriction of the mitral orifice), 
and the cirrhotic change in the liver, are often, no doubt, common re- 
sults of the same condition of the blood, viz: that to which we have 
above alluded. There are, no doubt, other exciting causes besides the 
ingestion of alcohol, but they can scarcely be particularized ; we be- 
lieve them to be in general such as increase the quantity and alter the 
quality of the fibrin of the blood. 

The next condition of the liver which we shall describe is that of 
fatty degeneration. A liver thus affected is usually much enlarged, 

Fig. 231. 




Section of liver in an advanced state of fatty degeneration. The cells are much broken up and fused 

together. 

paler than natural, and, in most cases, softer : sometimes, however, it 
has a feeling of great solidity. The capsule, in cases of uncomplicated 



516 ABNORMAL CONDITIONS OF THE LIVER. 

fatty degeneration, is not thickened, nor attached by adhesions to adja- 
cent parts. The thin edge of the organ is somewhat rounded, and the 
thickness generally increased. On microscopic examination, it is at 
once seen that the hepatic cells are engorged with oil : instead of con- 
taining a few minute drops imbedded in a mass of granulous matter, 
they are filled to the extent of one-half or two-thirds, or even their 
whole cavity, with colorless fluid oil. Sometimes a quantity of yellow 
matter is also seen in the cell-cavity, together with the oil, but this is 
often absent. The nucleus disappears, as is generally the case in cells 
that have fulfilled their work of secretion, but the envelop persists, and 
is sometimes a little thickened and striated. In very advanced cases 
the cells are not found merely gorged with oil, but, to a great extent, 
broken up and lost ; in their place there are seen only granular debris, 
entangling multitudes of oil-drops of different sizes. There seems to 
be less tendency to the development and growth of young cells than in 
the healthy state ; those that are forming appear stunted, and many be- 
come very early the seat of oily engorgement. The fatty change is 
very often confined to the margins of the lobules, and is always, we 
think, most advanced there ; sometimes, however, it may commence in 
the centres of the lobules. The pale condition of the liver depends on 
the enlarged size of the cells, which are pressed closer together, and 
thus constrict the capacious capillaries and allow less blood to be con- 
tained within them. There is, however, no obstruction to the flow of 

blood, such as we have seen in cirrhosis; 
Fig. 232. the soft state of the oil-laden parenchy- 

ma sufficiently accounts for this. We 
think it most probable that fatty degene- 
ration does not consist merely in the 
impletion of the cells with oil, in their 
containing a greater quantity of this 
matter than they naturally would, but 
that there is an actual impairment of 
their development and nutrition, of their 
active power of formation and secretion, 
so that the tissue really undergoes a kind 

(a) Empty envelop of an hepatic cell, ,, , T ^ » .,? . 

from which the oil has escaped. of decay. In support of this view, we 

(b) (c) (d) (e) Hepatic ceils containing may mention that we have scarcely ever 
muchoil - found sugar present in the parenchyma 

of a thoroughly fatty liver, while it can 
almost always be detected in livers that are not so affected; this is cer- 
tainly a remarkable fact, and seems to show that one very important 
function of the liver in such cases is, at least, very imperfectly dis- 
charged. It is an interesting fact, that the bile in these cases under- 
goes no constant or necessary alteration ; it is sometimes unusually pale, 
but often has the dark green tint of ordinary bile. The minute ducts 
are tolerably natural, and doubtless continue to discharge their part of 
the bile-secreting process. A fatty condition may coexist with a con- 
siderable degree of cirrhosis. The appearance of a section under the 
microscope is then very remarkable ; the lobules appear as opaque islets 




ABNORMAL CONDITIONS OF THE LIVER. 517 

separated more or less widely from each other, by more transparent 
spaces of fibroid tissue. 

There is a variety of the fatty liver which is termed the waxy. It is 
described by Rokitansky as having a color resembling that of beeswax, 
and being more consistent or firm, dry, and brittle than the ordinary 
fatty liver ; the color probably depends on the presence of yellow bile- 
pigment in the cells, and the increased firmness and brittleness on the 
oil being replaced by some of the more solid kinds of fat. 

The proximate cause of the production of fatty liver is, we believe, 
the existence of an undue quantity of oily matter in the blood, in pro- 
portion to the assimilative power. In cases of disease, it is also very 
probable that the vital power of the hepatic cells is much lowered. It 
may, therefore, occur : (1.) When an animal is largely fed on food con- 
taining much fat. (2.) When, in the course of an exhausting disease, 
rapid emaciation takes place, and causes the blood to become loaded with 
oil from the waste of the adipose tissue. (3.) When the type of respira- 
tion is low, and the blood necessarily, therefore, contains much hydro- 
carbonous matter. In the first and third class there may be simply 
accumulation of a large quantity of oil in the tissue of the liver; in the 
second there is generally, also, more or less degeneration of the hepatic 
structure. We have verified this by positive observation, as respects 
the first and second class. Animals fed for some time with fatty food 
have their livers loaded with oil, but the cells are not at all destroyed ; 
they contain much oil, and much also is deposited between them. We 
have found the liver, in persons dying, in a condition of extreme emaci- 
ation from other diseases besides pulmonary phthisis, in a complete state 
of fatty degeneration, and this has occurred so often, that we should 
expect to find it in most cases of great general wasting. It is certainly 
the emaciation of consumptive disease that produces fatty transformation 
of the liver, and not the mere destruction of the oxygenating apparatus. 
This statement is strongly confirmed by the analysis of about a hundred 
cases, in which we examined, microscopically, the condition of the liver. 
Among them, there were eighteen in whom the liver was thoroughly 
fatty, or nearly so; of them, only one died of pulmonary phthisis, four 
others of scrofulous affections, the remainder of diseases having no con- 
nection with any form of phthisis; ten cases of phthisis occurring in the 
same list, presented either no fatty degeneration, or an imperfect and 
partial change only. A fatty state of the liver is sometimes coincident 
with a similar condition of the kidneys, but not by any means invariably. 

Another form of degeneration of the liver, is that which Rokitansky 
has termed the lardaceous, or bacony. This term simply expresses the 
idea which the appearance of the morbid tissue conveys, and is, perhaps, 
preferable to that of scrofulous enlargement, which has been given to 
this form of disease by others, inasmuch as evidence is certainly wanting 
of the new deposit being identical or similar to any known kind of 
scrofulous matter. Rokitansky thus enumerates the characteristic fea- 
tures of this condition: "considerable increase of size and weight, with 
remarkable lateral development and flattening of the organ; smoothness 
and tenseness of the peritoneal investment; a certain degree of doughy 
consistency, combined with hardness and elasticity; anaemia; pale, watery, 



518 ABNORMAL CONDITIONS OF THE LIVER. 

portal blood; gray, grayish-white, or grayish-red color, tinged with yel- 
low or brown; the surface of a section being smooth and homogeneous, 
resembling bacon." In thin sections it is well seen, under the microscope, 
how the normal tissue is infiltrated with, and partly replaced by a ho- 
mogeneous, refracting substance; this forms small masses of various 
size, which lie heaped together between the hepatic cells, and so com- 
press and atrophy them, that they form in many parts a kind of wide- 
meshed plexus, the intervals of the plexiform bands being occupied by 
the glistening bacony matter. When liq. potassae is added, this matter 
loses much of its refracting power, and is reduced to mere delicate films; 
it shows no trace of organization, and seems to be deposited rather 
between than in the cells themselves. The cells, in such cases, often 
contain oily matter, or yellow pigment; the oil remains very apparent 
after the action of liq. potassae, and is very distinct indeed from the 
bacony matter. Deposits of similar matter are not uncommon in the 
spleen, and we have seen it also in the capillaries of the Malpighian 
tufts of the kidney and in the gastric mucous membrane. The exact 
nature of the substance thus deposited is unknown, but it is probably a 
variety of deteriorated albuminous matter. Neither does it seem to be 
special to any particular form of disease, but to occur generally in per- 
sons whose constitutions are gravely impaired. Rokitansky states it to 
concur with scrofulous and rickety disease, with syphilitic and mercurial 
cachexiae, and occasionally to appear as a sequel of remittent fever in 
cachectic persons. We have seen it produced in the spleen, as well as 
Bright's disease of the kidneys, apparently from the injurious drain on 
the system occasioned by an empyema, discharging externally. The 
presence of the abnormal matter in the tissue of the lobules causes ob- 
struction to the current of the portal blood; it is thrown back on the 
capillaries of the intestines, and ascites or sometimes diarrhoea results. 
The next morbid condition of the liver which we shall consider is that 
which exists in the various affections in which jaundice forms a promi- 
nent symptom. There is little doubt that in most cases a jaundiced 
condition of the liver precedes and occasions a similar condition of the 
whole body. General jaundice is commonly supposed to depend upon 
the absorption into the blood of bile that should have passed out into 
the intestine, and this is, doubtless, the cause of it in many cases. In 
these, the bile locked up in the substance of the liver causes it to be 
tinged yellow, a result which we have produced artificially by placing a 
ligature on the duct. com. choled. in animals. But in many cases more 
than this occurs. Dilatation of the heart, or obstructive valvular dis- 
ease, throwing back the blood on the venous system, occasions perma- 
nent congestion of the liver, and often produces the condition termed 
"nutmeg" in its most marked form. In this, as before described, the 
congestion is exactly coextensive with extreme yellow engorgement of 
the cells ; a much larger quantity of yellow matter is contained in the 
liver; there is hepatic jaundice, and together with this, and, no doubt, 
in consequence of it, general jaundice frequently occurs. In these 
cases, we think the evacuations continue of their natural color; a certain 
quantity at least of bile flows into the intestine. In most healthy ani- 
mals the cells of the liver have only a very faint, if any, yellow tinge, 



ABNORMAL CONDITIONS OF THE LIVER. 519 

but, by repeated doses of calomel, we have caused the production of a 
large quantity of yellow matter in the cells ; there is evidence also to 
show that the same has occurred in the human subject. In the acute 
yellow atrophy, as Rokitansky names that condition of the liver which 
is found in cases of jaundice occurring often in several members of a 
family, one after another, attended with symptoms of toxaemia, and 
proving fatal by coma, there must certainly be a greatly increased pro- 
duction of yellow pigment. The flow of bile into the intestine is not 
so completely stopped as it is in other instances of jaundice, and the 
yellow coloration of the liver is deeper than it is almost ever seen. 
Icterus neonatorum appears also to be an instance of the excessive pro- 
duction of bile or of bile pigment: there is evidently no disease of the 
liver, or any obstruction in the biliary ducts, but owing to the organ at 
birth being highly congested with blood, and the system not having 
adapted itself to its new condition, a greater quantity of yellow pigment 
is formed out of the coloring matter of the blood than can be readily 
carried off by the bile; this again returns into the blood and produces 
jaundice. This explanation seems preferable to that which assigns a 
kind of hyperaemic, or half-bruised state of the skin, as the cause of the 
yellow stain; were this so, how could the conjunctiva come to be affected? 
When jaundice occurs in the course of fevers or in pyaemia, it then depends, 
in all probability, on an alteration taking place directly in the haematin 
of the blood, which, as in the case of an extravasation, is changed from 
a red to a yellowish tint; in this case, there would be no preceding 
jaundice of the liver. It is evident that, in all instances of jaundice, 
the unnatural tint results from the presence of a yellow (usually identi- 
cal with bile) pigment in the blood ; this is easily demonstrable in the 
urine and other secretions, by the stain imparted to linen, or by the play 
of colours which it gives with nitric acid; but there is little or no evi- 
dence to show that real biliary matter is present in the blood or the 
secretions. From jaundiced livers plenty of yellow pigment can be ex- 
tracted, reacting with the nitric acid test, but no cholic acid, or any 
substance that gives the reaction of Pettenkofer's test. The blood, in 
cases of jaundice, is more often found to contain bile-pigment without 
cholic acid, than the reverse. The same is the case with the urine; it 
often gives a characteristic reaction with nitric acid when none is 
afforded by the test of sugar and sulphuric acid. From these data, we 
must conclude that jaundice depends on the presence of bile-pigment, or 
some similar modification of haematin in the blood ; but that it is by no 
means certain that bile, as such, is actually present. It may be that, 
in the graver cases of jaundice, attended with toxaemia, cholic acid, or 
some modification of it, is present in the circulation in large quantity, 
as well as yellow pigment. The color of the liver in jaundice is of a 
more or less marked yellow, in some cases passing to a green or brown- 
ish tint; this will be, of course, modified, and more or less concealed by 
the blood contained in the vessels. There is no other particular change 
to be noticed except in the acute yellow atrophy. Here, the color of 
the organ is an intense yellow ; its texture is flabby, a section shows 
nothing of the natural lobular arrangement ; its size is greatly dimi- 
nished, and it seems almost or quite bloodless. The blood in the large 



520 ABNORMAL CONDITIONS OF THE LIVER. 

vessels, is said by Rokitansky to be reduced in consistence, and of a 
dirty reddish-brown color, and the coats of the V. Portae to be tinged 
with bile. Under the microscope, it is seen that the cells are completely 
destroyed, and even their nuclei have perished; the parenchyma is a 
mere mass of broken-up granular matter, tinged deeply yellow and con- 
taining some largish yellow masses, together with diffused oily matter. 
In one instance which we examined, no sugar could be extracted from 
the liver, though it is usually abundant in healthy organs ; this may, 
however, have depended on the non-ingestion of food for some time be- 
fore death. The minute ducts we have found gravely altered; they had 
lost their natural structure, and were filled with subgranular matter and 
opaque whitish globules. These globules, probably a kind of concrete 
oily matter, were very abundant in the lymphatics, and rendered their 
course remarkably distinct. 

The following may be enumerated as adventitious growths in the liver : 
(1.) Lipomatous tumors. (2.) Cavernous tissue. (3.) Tubercle. (4.) 
Hydatids. (5.) Cancer. The lipomatous tumor is very rare, and, 
according to Rokitansky, seldom larger than a pea. Cavernous tissue 
is said by this celebrated pathologist to be of frequent occurrence ; we 
doubt, however, whether this is the case in England. Its size varies 
from that of a hempseed to that of a hen's egg, or still larger ; it is of 
dark color, from the quantity of blood occupying its cells, and is thus 
seen through the peritoneum of the surface more or less prominent, 
according to the degree of distension. If its cells are empty, it is found 
collapsed and shrunk. These growths may be single or numerous. 
Tubercle is a deposit not very unfrequent in the liver, at least to a small 
amount, but it is very rare that it forms large masses, or that it under- 
goes softening or other changes. It most frequently appears in the 
shape of semi-transparent, grayish, miliary granulations, or of yellow 
crude tubercle; the masses are of a small size, seldom larger than, or 
even so large as, a pea ; they are generally few in number and widely 
scattered. We think we have often seen nodules of fibrin deposited in 
the substance of the liver, which might easily have been confounded with 
the miliary granulations ; their microscopic characters would sufficiently 
distinguish them. Rokitansky mentions a state of acute tuberculosis as 
occasionally affecting the liver ; it is found then u in a peculiar state of 
turgescence, the tissue relaxed, friable, pale, and gorged with a serous 
or sero-sanguineous fluid." Such an occurrence indicates a high degree 
of tuberculous dyscrasia, "a tendency to universal tubercular deposition, 
and especially in the abdominal viscera." The tubercle thus tumult- 
ously deposited occasionally softens and breaks down, but not exactly in 
the way of suppuration that it does in the lungs, and thus an hepatic 
vomica may be formed, "which offers no peculiar characters beyond the 
biliary discoloration of its contents." It appears that such a vomica 
may be occasionally confounded with a condition to be subsequently 
described, in which a cystic dilatation of the minute biliary ducts takes 
place, the cavities of the cysts becoming filled with a whitish cheesy 
matter. 

Hydatid cysts are of frequent occurrence in the liver, more so in this 
than in any other organ. Sometimes they are single, sometimes there 



ABNORMAL CONDITION'S OF THE LIVER. 521 

are several separate cysts. They often attain a considerable size. Ro- 
kitansky mentions one in the Vienna Museum of a foot in diameter, 
and we have very recently examined one of an oval form, whose long 
diameter measured six inches. Their usual site is the right lobe, and 
the largest are generally found here, but the one just mentioned was 
situated at the extremity of the left, and had grown in, and far beydnd, 
the left lateral ligament. As their size increases, they rise to the sur- 
face of the liver, and sometimes excite inflammation of the serous mem- 
brane, by which adhesions are formed connecting them with the parts 
adjacent. The prominent part is, of course, that where least resistance 
is offered to the pressure of the fluid within, and its wall may hence 
atrophy and give way, or be destroyed in the course of suppurative in- 
flammation, and the contents thus be effused into some neighboring 
cavity. The cysts have been known to burst into the peritoneal sac, 
into that of the right pleura, or into the bronchi of the corresponding 
lung, into the duodenum or transverse colon, and in some rare instances, 
into a large bloodvessel or branch of the hepatic duct. When the 
tumor, in its progress, causes ulceration of one of the smaller ducts, 
which is not uncommon, bile makes its way into the cavity, mingles 
with and tinges its contents, and very often excites suppurative inflam- 
mation of the walls of the sac. This seems to be the reason that hydatid 
tumors in the liver suppurate much more frequently than those in other 
parts. 1 Other circumstances, however, may certainly cause these cysts 
to inflame and suppurate. The detailed description of the structure of 
hydatid cysts will be found under the head of Parasites, p. 218 ; it will, 
therefore, be sufficient to mention here that they possess an outer wall 
or envelop, formed of condensed areolar tissue and that of the surround- 
ing structure ; within which, and rather loosely adhering to it, is the 
proper membrane. This is white and laminated, and is itself lined in- 
ternally by a softish layer in which the echinococci are developed. The 
cavity of the primary cyst is occupied in some instances by a transpa- 
rent limpid fluid only ; in others, and the majority, it also contains a 
numerous progeny of secondary cysts, which may themselves contain 
another generation. Dr. Budd mentions the interesting fact, that in 
cases where suppuration has occurred in the cavity of the primary cyst, 
the secondary hydatids, though floating in purulent matter themselves, 
contain a perfectly limpid fluid. He also points out characters whereby 
to distinguish between an abscess and a suppurated hydatid cyst, in the 
differences which the cystic membranes in the two cases present. That 
of an abscess consists of dense fibroid tissue, is not laminated, and never 
contains calcareous matter. The hydatid membrane does not adhere so 
firmly to the surrounding tissue, is markedly laminated, and in old cases 
contains very often plates or grains of calcareous matter in its coats. 
When an hydatid tumor has evacuated its contents as above described, 

1 Some doubt may exist whether the purulent-looking fluid contained in the cyst is 
always true pus. In a case occurring at St. Mary's Hospital, the matter from the inte- 
rior of a large cyst, which had to the naked eye all the appearance of pus, was found 
under the microscope to consist of much granular and oily matter, with some choles- 
terin, and numerous utterly irregular granular masses. There were no true pus- glo- 
bules. 



522 ABNORMAL CONDITIONS OF THE LIVER. 

it may collapse and a cure be effected ; but if its walls are very thick 
and firm, and the cavity large, its obliteration in this way may be im- 
possible, and thence there is too much reason to fear that, owing to the 
entrance of air or other matters, suppurative inflammation of the sac 
will be excited, and the drain exhaust the strength of the patient. But 
an hydatid cyst may come to a spontaneous cure in a different way ; its 
proper membrane, instead of secreting a watery fluid may produce a 
putty-like matter, consisting of phosphate and some carbonate of lime, 
with cholesterin and albuminoid matter. This accumulates within the 
sac, or sometimes around it, imbeds the secondary hydatids, and causes 
them to shrivel up and perish. Such a change reminds one forcibly of 
the cretification of tubercle, which is often observed in cases where the 
tubercular dyscrasia has ceased, and the deposited matter has been par- 
tially absorbed. Hydatids in the liver are not unfrequently associated 
with hydatids in other parts, in the lower lobes of the lungs, or in the 
spleen, or in the mesentery ; in such cases, Dr. Budd is inclined to regard 
the hepatic cyst as the parent, and the others as originated from germs 
conveyed from it. The arguments which support this view are, the 
greater apparent age of the hepatic cyst, and the circumstance that the 
one " in the liver is associated only with cysts in the lung or in the 
mesentery;" this seems to indicate rather that the one is derived from 
the other, than that both are of independent origin. It is also to be 
remarked that an hydatid cyst often occurs in the liver alone, but rarely, 
if ever, alone in the spleen or mesentery. These arguments are, cer- 
tainly, of weight, but seem hardly sufficient to counterbalance the objec- 
tions, that it is difficult to conceive how a germ from the hepatic cyst 
should make its way backwards against the stream of blood to the spleen 
or the mesentery, and that it cannot be considered improbable that a 
second hydatid should originate in a different locality, in a system 
which has already shown itself favorable to the production of a pri- 
mary one. 

Cancerous disease is very frequent in the liver : it stands fourth in 
the list of organs thus affected, according to the Parisian registers ; 
these show that it occurs about once in every sixteen cases of cancer : 
Rokitansky estimates its occurrence in the liver to be much more fre- 
quent ; he states " its numerical relation to carcinoma of other organs, 
as 1 : 5." The above statements do not, of course, refer to primary 
cancer of the liver only, but include secondary cancer also. Three 
varieties of cancer have been observed in the liver ; colloid is extremely 
rare, neither Dr. Budd nor Dr. Walsh has met with it ; Rokitansky 
seems only to have seen a single case, and he does not state whether it 
was primary or secondary. Scirrhus is not very unfrequent, or a tran- 
sition variety between it and encephaloid : it constitutes roundish tumors, 
about the size of a large nut, whitish, fibrous, and tolerably firm. En- 
cephaloid is far the most common, and, as in other parts, attains far 
the largest size. We have seen almost the whole organ converted into 
a mass of this kind. It sometimes forms separate tumors, sometimes 
infiltrates the parenchyma. Rokitansky's description of the separate 
tumors seems to us to apply equally to the scirrhous and encephaloid 
varieties, as he himself appears to allow. He says : " Their general 



ABNORMAL CONDITIONS OF THE LIVER. 523 

form is spherical, though their surface not unfrequently is slightly race- 
mose or lobulated. Those which have been developed in the peripheral 
portion of the organ, and are, therefore, in contact with the peritoneum, 
present a flattened or even an indented surface, and the indentation may 
extend to the very nucleus of the morbid growth. The peritoneal 
lamina in the indentation is opaque and thickened," probably from 
having become involved in the cancerous degeneration ; it seems to be 
retracted and drawn in much the same way as the skin is in subcuta- 
neous cancer. The number of the cancerous tumors varies in different 
cases ; they may be solitary or very numerous ; primary cancers are 
usually few, secondary may amount to some hundreds. Dr. "Walsh thinks 
they are most numerous when they occur consecutively to cancer of the 

Fig. 233. 




Encephaloid growth, occupying a large extent of the liver. 

stomach. The scirrhous tumors have scarce any investments of cellular 
tissue, and adhere closely to the surrounding hepatic parenchyma ; the 
encephaloid have a delicate cyst-like investment, though this does not 
seem to be constant, and they can be detached more readily. u Infil- 
trated encephaloid," according to Rokitansky, "always contains oblite- 
rated and obsolete bloodvessels, and ducts which are gradually absorbed. 
The infiltration attacks larger or smaller segments of the viscus ; it does 
not present distinct boundaries, but insensibly passes into the normal 
parenchyma. It rarely occurs without nodulated cancer." The sepa- 
rate tumors often inclose strata of remaining hepatic structure, a fact 
which seems to mark a connection between the two forms ; some degree 
of infiltration taking place in each; but in one, the growth simply pushes 
the parenchyma aside, in the other it spreads its germs everywhere 
among its elements.. The structure of cancerous tumors presents no- 
thing different from that of cancerous tumors in other parts, and is de- 
scribed under the general head of cancer (p. 187). Their degree of 
vascularity varies : some tumors show very little trace of bloodvessels, 
others are richly supplied, and are the seat also of interstitial effusions 



524 ABNORMAL CONDITIONS OF THE LIVER. 

of blood ; to such, the terra haematoid or fungus hsematodes is appro- 
priate. Black pigment often is scattered through the substance of the 
growths, and may be so abundant as to make them appear entirely black. 
These claim, of course, the appellation melanotic. 

Cancerous tumors in most cases produce considerable enlargement of 
the liver, the atrophy of the proper tissue which they occasion being 
more than compensated by the amount of their own enlargement ; in 
some rare cases, however, this does not take place, and the liver, though 
containing many cancerous tumors, is smaller than natural. Masses of 
cancer which appear on the surface of the liver, sometimes excite adhe- 
sive inflammation of the investing serous membrane, and thus become 
united by false membrane to adjacent parts. Instead of this, they have 
been known to infect with their tainted fluids the parts in contact with 
them, and to cause secondary formations of cancer in them, or to extend 
into them, by the ordinary way of infiltration. Ascites, to some extent, 
is not unfrequently produced by the presence of cancerous masses in 
the liver : this probably depends on the obstruction of the portal vein- 
branches, either by the tumors themselves, or by cancerous matter de- 
veloping in them, or by fibrinous effusion coagulated within their chan- 
nel. Jaundice is often observed in cancerous disease of the liver ; its 
production, doubtless, takes place in the same way as that just noticed ; 
the gall-ducts being obstructed, and the escape of bile from various 
parts of the organ prevented. When the masses are so situated as to 
press on the common duct leaving the others free, enormous distension 
of the gall-bladder may take place — it has been seen as large as the 
foetal head ; such a result, however, is more likely to be produced by 
cancerous disease of the head of the pancreas, than by growths in the 
substance of the liver. Primary cancer of the liver is stated by Dr. 
Budd, seldom, if ever, to occur before the age of 35 : from this to 55 
is the epoch at which it most frequently manifests itself. Secondary 
cancers of the liver may occur at any age : they seem, according to Dr. 
Walsh, to affect a preference for the superficial parts of the organ. 
They are believed to be produced by the transportation of germs in the 
blood, or by the medium of the lymphatics; this, doubtless, is often true, 
but we certainly are of opinion that fluid cancerous blastema is quite as 
adequate to their production as any solid particle, and this cannot but 
be absorbed by blood passing through a malignant tumor. There seems 
evidence to show that when the part primarily affected returns its blood 
to the liver directly, as in the case of cancer of the stomach, the infec- 
tious matter is all detained there, and tumors are not formed in other 
parts ; but when hepatic cancer is consecutive to cancer of the breast, 
its development must then depend on the absorbed matter finding a 
suitable nidus in that organ. A sort of spontaneous cure of hepatic 
carcinoma has been occasionally observed, the, morbid growth becoming 
converted into a fatty mass, doubtless by a change of the nature of 
fatty degeneration. 



ABNORMAL CONDITIONS OF THE BILIARY PASSAGES. 525 



ABNORMAL CONDITIONS OF THE BILIARY PASSAGES. 

Malformations. — The gall-bladder is sometimes wanting — in animals 
it has been found double ; its shape may be variously deformed ; its 
duct, as well as the common duct, may probably be imperforate. The 
cystic and hepatic duct may remain separate, and communicate either 
both with the duodenum, or one with the duodenum and the other with 
the stomach. The mucous lining of the gall-bladder and ducts is often 
attacked with inflammation, which may extend from the duodenum, and 
spread upwards along the ducts. It is often of the catarrhal kind, and 
is essentially similar to the affection of the gastro-intestinal mucous 
surface ; like it, subsiding after a time, and leaving no traces of its 
existence behind. The effects it produces will be those of vascular in- 
jection, some degree of tumefaction, shedding to a greater or less extent 
of the epithelium, and casting off of mucous corpuscles and various 
forms of immature epithelia, together with exudation of liquor muci, of 
various degrees of viscidity and tenacity. The gall-bladder alone may 
be the seat of acute idiopathic inflammation, or this may be excited by 
unhealthy bile, or, perhaps, by the irritation of a calculus. The result 
of such inflammation may be closure of the cystic duct, and conversion 
of the gall-bladder into an abscess. If the catarrhal inflammation, or 
that set up in any other way, attain a certain degree of intensity, it 
causes the effusion of muco-purulent or purulent matter, and at the 
same time it seems to induce paralysis of the contractile coat of the 
biliary ducts ; these tubes, thus weakened, yield to the distending force 
within of the accumulating secretion, and become dilated at intervals 
into cyst-like pouches, filled with muco-pus tinged yellow or green by 
bile. The dilatation will, of course, be promoted, if the common duct, 
or the hepatic, is obstructed by a calculus, or in any other way. After 
such pouches have existed a certain time, they become entirely cut off 
from the duct in which they originated, the tube becoming obliterated 
by adhesion, and their contents then undergoing certain changes. Thus, 
the muco-purulent matter may be converted into a clear glairy fluid, 
more or less tinged with bile ; we have recently observed a case of this 
kind, and though we were some time in doubt as to the nature of the 
cyst, which was found in a healthy liver, we were soon convinced by 
detecting particles of columnar epithelium in the matter lining its sur- 
face ; besides the fluid in this case, there were several small whitish 
masses attached to the inner surface, consisting of a semi-homogeneous, 
semi-granulous, soft substance, containing imperfect celloid forms. It 
seems probable that, had the person survived longer, these whitish masses 
would have increased considerably, so much as to fill the cyst, and that 
in this way one of those peculiar tumors would have been produced which 
Dr. Budd has called "knotty tumors of the liver," and which he believes 
to be formed within the ramifications of the hepatic ducts. He describes 
them as firm, white nodules, surrounded by a distinct cyst, and contain- 
ing a cheese-like substance, in the centre of which is a small mass of 
concrete biliary matter ; they are evidently situated in portal canals, 
and have often been mistaken for cancerous tumors. We think it is too 



526 ABNORMAL CONDITIONS OF THE BILIARY PASSAGES. 

much to assume that all such tumors as contain a glairy fluid have origi- 
nated in catarrhal inflammation ; probably the morbid, cyst-producing 
action is in many cases of a more chronic kind, and the fluid is glairy 
from the first. In a boy who died with pneumonia supervening on a 
tuberculized state of the lungs, we found the liver, with the exception 
of marginal oily accumulation in the lobules, and a somewhat atrophied 
condition of the cells, apparently healthy, except that here and there 
throughout its substance there were seen green-colored spots of the size 
of a pin's head. These seemed to exist about the termination of the 
minuter portal canals, and were, doubtless, connected with the terminal 
ducts ; they consisted of yellow and orange or reddish pigment coloring- 
matter, heaped up together and forming a mass which encroached on 
the parenchyma; in one of them, columnar epithelial particles were 
seen, proving that a duct was involved in it. The cells contained no 
yellow matter, so that it was evident that these green masses had been 
produced by a morbid action set up in the minute ducts. Ulceration of 
the gall-bladder is not unfrequent ; it may occur as a consequence of 
suppurative inflammation, or be set up in an organ which has been the 
seat of chronic disease, or occur in the course of remittent or typhoid 
fever, or be produced by the irritation of calculi, and probably also by 
that of unhealthy and acrid bile. The ulcers are sometimes small and 
numerous, sometimes there is but one large one ; they are sometimes 
attended with sloughing of the coats, and sometimes go on to perforate 
the wall completely. When this happens, the bile, if the gall-bladder 
contain any, escapes into the cavity of the peritoneum, and rapidly 
excites fatal inflammation. If, from long closure of the cystic duct, the 
gall-bladder contains no bile, but only a mucous or serous fluid, this does 
not escape so rapidly, and the inflammation is more limited to the neigh- 
borhood of the liver. When ulceration is excited by the presence of 
gall-stones, it usually happens that the bladder becomes adherent to 
some adjacent part, commonly the colon or duodenum; and, as the pro- 
cess advances, a communication is established between the two viscera, 
by means of which the calculus escapes into the bowel, and may be dis- 
charged. We have, however, seen a case in which fatal obstruction of 
the intestines was occasioned by a gall-stone, which had probably escaped 
by a fistulous opening from the gall-bladder. We do not know much of 
ulceration of the ducts ; the smaller branches are so rarely examined, 
that its existence may have been overlooked. Dr. Budd records one very 
interesting case, in which an ulcer of the common duct made its way 
into the superior mesenteric vein, close to its termination in the portal; 
the result was phlebitis of the vessel, and purulent formations in various 
parts of the liver and the lungs, as well as in the skin and subcutaneous 
tissue of the head and face, and in some other parts also. If inflamma- 
tion, attended, probably, with some amount of ulceration, attack the 
cystic duct, obliteration of its channel may be the result ; or the same 
may be occasioned by a gall-stone lodging there. The gall-bladder now 
has become a closed sac; the bile which it contained is gradually absorbed 
and replaced by a mucous or glairy fluid ; this is at first so abundant as 
to convert the bladder into a dense capsule, resembling, according to 
Kokitansky, the sound of fishes; but afterwards this fluid is reabsorbed, 



ABNORMAL STATES OF THE BILE. 527 

and the gall-bladder contracts and shrivels. Cholesterin is often present 
in great abundance in the fluid contents of such gall-bladders; this is 
especially the case when the coats are diseased and thickened. The loss 
of the biliary reservoir seems to have no injurious effect on the health. 
The duct. com. choled. may be closed by concretions, cancerous growths, 
or croupy exudation : the outflow of the bile being thus prevented, it 
collects within the ducts, and causes general dilatation of them. In 
such cases, Rokitansky says, the liver is in a condition resembling that 
of yellow atrophy, the parenchyma of a dark-yellow or green color, 
turgid, though pulpy and friable. Dr. Budd, in the case he records, 
describes it as of a deep olive, finely mottled with yellow; the tissue 
flabby, but not easily broken down ; the lobules undistinguishable. The 
cells in this and in another case were destroyed, and only granular and 
oily debris, mingled, in Dr. Budd's case, with yellow matter, remained. 
In two cases which we have observed, the cells were not destroyed; they 
had a yellow or greenish tint, and were rather stunted, but not at all 
broken up. We injected in one a large dilated duct, and obtained the 
important result that the terminal ducts were not dilated, and were of 
about the same size as in healthy livers. Rokitansky says that "this 
affection invariably proves fatal with symptoms of biliary infection of 
the blood and consequent cerebral disease, which is often combined with 
exudation on the arachnoid, with intense icterus, and extreme pain in 
the liver." In Dr. Budd's case, there were no symptoms of cerebral 
poisoning, and the mind remained clear to the last. 

Croupy inflammation occasionally, but very rarely, attacks the gall- 
ducts. " It gives rise to tubular exudations, in which the bile forms 
branched concretions, which block up the passages, and thus cause dila- 
tation of the capillary gall-ducts." The coats of the gall-bladder may 
become cedematous in dropsy, or the subserous tissue infiltrated, as in 
peritonitis ; increased deposit of fat may also take place in the latter 
situation, and, perhaps, induce (coincide with ?) fatty degeneration of 
the muscular layer. Rokitansky also notices the formation of osseous 
plates in the thickened parietes of gall-bladders which have been the 
seat of inflammation, an and increased production of fibroid tissue, which 
may be so firm and white as to give a cartilaginoid appearance. The 
biliary ducts very rarely contain tubercle. Cancer sometimes extends 
to the gall-bladder from the liver ; or, it is said, may occur in it prima- 
rily ; it forms nodules in the submucous tissue, or infiltrates the mucous 
membrane ; more commonly, its wall is perforated by growths in the 
liver, which push their way into its cavity. 



ABNORMAL STATES OF THE BILE. 

A brief account of the various unhealthy states of the biliary secre- 
tion will properly follow here. It must be premised, however, that our 
knowledge of these states is extremely imperfect, from the bile being, 
unlike the urine, almost inaccessible in the living subject to our ob- 
servation, and from the changes which it spontaneously and rapidly 
undergoes. It may be secreted in too great quantity, as commonly 



528 ABNORMAL STATES OF THE BILE. 

happens to Europeans on first arriving in India, and occasions a bilious 
diarrhoea. The same thing often happens in our own country in au- 
tumn, and from the same cause, probably, viz : increased excitement of 
the liver. The converse of this sometimes occurs, bile is secreted in 
too small quantities, or for a time ceases to flow altogether. This pro- 
duces pain and uneasiness in the bowels, which are relieved when the 
bile flow returns. It seems that bile is the natural and healthy stimu- 
lus to the intestines, and that, if it is absent, the other contents, acid, 
and, perhaps, in other ways irritating, tease and distress the sensitive 
mucous membrane. We cannot judge correctly of the bile that has 
been poured out of the liver by that which we find in the gall-bladder, 
for the latter may be unnaturally dark and viscid, or otherwise altered, 
simply in consequence of its continued sojourn there. Still, in many 
cases, we have no other source of information, and from this we must 
form the best judgment we can. In cirrhosis, Dr. Budd says, the bile 
is often thin or serous, and of an apricot or orange color; in other 
similar cases it has its natural appearance. Sometimes it is black and 
thick. In yellow atrophy, the gall-bladder generally contains but little 
bile, often only some mucous fluid, tinged yellow or green : the hepatic 
ducts have been found quite devoid of any biliary tinge. In cases of 
fatty liver the bile is sometimes unusually pale. We have seen it, how- 
ever, of a deep greenish color ; and this is also the case in fishes in 
which the fatty condition is natural. In the lardaceous or bacony con- 
dition, Lehmann speaks of the bile as light-colored and watery. In 
tuberculosis, the bile is often found poorer in solid contents, but some- 
times also more rich in them. Extensive inflammations, especially 
pneumonia and diabetes, are said to render the bile more watery. This 
occurs also in some cases of typhus and disease attended with dropsy. 
The solid contents, according to Lehmann, of the bile are increased in 
diseases of the heart, and those abdominal (others also ?) affections in 
which the motion of the blood in the larger veins is delayed. The bile 
in malignant cholera is very thick and tenacious, and is like the blood 
manifestly drained of its water. In this disease, and in Morbus Brightii, 
urea has also been found in the bile. Albumen seems to have been 
found occasionally in bile ; Lehmann says that it has been observed in 
cases of fatty liver, of Bright's disease, and in the embryonic state. 
The quantity of mucus is often relatively increased when the bile is 
very dilute ; this has been noticed in typhus fever. Free oil is occa- 
sionally seen in bile, and probably always might be during decomposi- 
tion of this fluid. The bile is very rarely acid ; this has been observed 
in cancer and typhus ; it probably depends on some of the acids being 
detached from their bases. The foregoing statements are very unsatis- 
factory ; and, perhaps, the only definite conclusion that can be drawn 
from them is, that there is no constant relation between the condition 
of the parenchyma and that of the secreted bile, nor between the latter 
and the greater number of the various diseases to which the body is 
liable. Obviously, they tell us nothing as to the varying condition of 
the resinoid biliary acids, the essential constituents of the bile. Two 
conditions, however, of the bile in the gall-bladder deserve our close 
attention, on account of the important consequences which often result 



ABNORMAL STATES OF THE BILE. 529 

from them. One is, the bile being so loaded with coloring matter from 
concentration, or other causes, that a deposit of this substance takes 
place ; the other is, the bile containing a large quantity of cholesterin. 
From these two substances all biliary calculi almost are formed. They 
are far most common in the gall-bladder, but also occur in the ducts, 
both within and without the liver. " Their 1 form and surface vary 
much. Single calculi are commonly round, oval, or cylindrical ; when 
very large so as to occupy" the entire cavity of the gall-bladder, they 
are frequently slightly curved ; " if many exist together they mutually 
prevent their enlargement, and, in consequence of the friction and pres- 
sure they exert upon one another, they assume cubical, tetrahedric, 
prismatic, or irregularly polyhedric shapes, with convex or concave sur- 
faces. The calculi found in the ducts are generally cylindrical, occa- 
sionally branched, or entirely amorphous. The texture of the calculi 
may be uniform or varied, in proportion as they consist of one substance 
or of several layers. Many show no distinct arrangement ; some have 
an earthy pulverulent fracture, or a fibrous, striated, laminated, mica- 
ceous texture, as is particularly observed in calculi consisting of cho- 
lesterin." Gall-stones are not of any great 
degree of consistence ; they may sometimes be Fig. 234. 

compressed easily between the fingers : they ££ 

are rather light, but not so much so as to 



float in water. Their color varies from a milky- jflP t&8 f&iih 

brown : internally, they often present an alter- IP^ ™ fir ^^ 



white to various shades of green, yellow, or 



nation of different-colored laminae. They may 0& &L ^ 

be said to consist generally of cholesterin, *^ 

mingled with a combination of pigment and Small > irregular gall-stones, com- 

lime in various proportions. Large gall-stones, JT* of inspis f ted and al * ered 

.. .**„.'■.. , . ° ° . , 7 Due cemented by mucus. — From 

with the exception ot their nuclei, consist almost Dr . B udd's work, 
entirely of cholesterin, and are, therefore, 

whitish and crystalline ; their sectional surface presenting a number of 
striae radiating from the centre. Small gall-stones, resembling grains 
of black pepper, of an irregular, tuberculated form, and almost black 
color, are occasionally found: they consist almost entirely of pigment 
and earthy matter, the carbonate and phosphate of lime. Cholesterin 
generally forms the principal mass of biliary calculi ; it often alternates 
with layers of pigment, and almost always itself surrounds a nucleus of 
the same matter. 

The secretion of a large quantity of cholesterin does not seem to be 
the essential and adequate circumstance for the formation of gall-stones; 
the gall-bladder sometimes contains mucus loaded with sparkling tablets 
of this substance, without any trace of calculi. It seems most probable 
that pigment-granules cemented together by mucus first constitute a 
nucleus, round which cholesterin afterwards is deposited in layers. 
Other matters, however, may serve as a nucleus; blood, a portion of a 
distoma, or a lumbricus, or even a pin, are said to have been found in 
this situation. 

1 Rokitansky, vol. ii. p. 162. 

34 



530 



ABNORMAL STATES OF THE BILE. 



Fig. 235. 




From a gall-bladder, which 
was shrunken, a calculus 
being impacted in the cystic 
duct. 

(a) Cholesterin tablets. 

(b) Glomeruli. 



Fig. 236. 




Gall-bladder and cystic 
duct, containing calculi, 
which have a crust of pure 
cholesterin. The two upper 
are divided. — From Dr. 
Budd'a work. 



Gall-stones are not peculiar to, or especially 
associated with, any condition of the liver — they 
are said to be most frequent with cancer, but very 
often occur in other states; they are more often 
found in females than males, in the proportion of 4 
or 5 : 1 — rarely before, but often after the middle 
period of life. A sedentary life, and obese condition 
of body, are favorable to the formation of gall- 
stones; they are not, however, unfrequently present 
in lean and temperate persons. As cholesterin is 
a variety of fatty matter, this might seem surpris- 
ing, did we not remember that its formation may 
be referred to a kind of fatty degeneration, as well 
as to the presence of an increased quantity of oil 
in the system. Cholesterin is certainly secreted 
often in large quantity by the thickened coats of 
the gall-bladder, and by additions from this source 
the large solitary calculi are probably formed ; there 
is no doubt, however, that in other cases it is de- 
posited from the bile, owing to the decomposition 
of the taurocholic acid or its salts, by which it is 
naturally held in solution. Calculi are often loose 
and free in the cavity of the gall-bladder ; some- 
times they are attached to its surface by exudation, 
or included in compartments formed by organized 
lymph. Small ones are sometimes, also, contained 
in saccular dilatations of the mucous membrane, 
and may appear to lie external to the cavity of the 
gall-bladder. The following effects are produced 
by biliary calculi : They become impacted in the 
cystic duct, and occasion its obliteration, the gall- 
bladder undergoing the changes that have been 
described. The same thing occurs, but much more 
rarely, in the common duct, which is straighter and 
wider; great distension of the gall-bladder and ducts, 
and occasionally rupture of the former, then take 
place. If, on account of the angular shape of the 
stone, the duct is only partially obstructed, the same 
effects are produced, but in a less degree. While 
lodged in the gall-bladder, calculi may excite irri- 
tation, thickening, inflammation, and suppuration 
of its coats, and sometimes ulceration. Of these 
we have lately spoken. 

Acephalocysts, and the distoma hepaticum, oc- 
cur in the gall-bladder. For a description of them, 
vide art. Parasites, p. 199. 



CHAPTER XXXIV. 

ABNORMAL CONDITIONS OP THE PANCREAS, AND THE 
OTHER SALIVARY GLANDS. 

These are not very numerous. Congenital deficiency is observed 
only in very imperfect monstrosities, and excess of development is very 
rare. Hypertrophic enlargement, Rokitansky states, is altogether un- 
usual, and when it does occur, affects chiefly the cellular tissue, which 
is interwoven with the glandular tissue. We have, however, examined 
one specimen in which the ultimate vesicles were stuffed with epithelium 
to such a degree, that their investing fibroid envelops appeared stretched 
and distended, and the whole gland was of a very remarkable density. 
We think minor degrees of this condition are not uncommon. 

Atrophy of the pancreas takes place in some instances spontaneously, 
chiefly in advanced age; or it may result from chronic inflammation, or 
fatty degeneration. The organ may be soft and lax, or of leathery 
consistence. 

Inflammation, at least in the acute form, but rarely attacks the 
pancreas; it is, however, not infrequent in the other salivary glands, 
where it constitutes the disease termed mumps. We have seen inflam- 
mation and suppuration of the parotid gland occur as the result of fever. 
The phenomena of inflammation are the same here as in other similar 
parts. The gland swells considerably, partly from the congestion of its 
vessels' with blood, partly from exudation into the areolar tissue which 
envelops it. In the ordinary case of mumps, suppuration rarely takes 
place, and simple resolution occurs; but when the result is less favorable, 
the glandular structure becomes, in a measure, fused with the interstitial 
exudation, and probably penetrated by it also, and the whole mass softens 
and breaks down into purulent matter. This had occurred in the case 
of fever above alluded to. The suppuration may affect the whole gland, 
or be limited to distinct spots, and form an abscess. " Chronic inflam- 
mation induces condensation, induration of the cellular tissue, obliteration 
of the acini, and either permanent .enlargement, or subsequent atrophy 
of the gland." A specimen of this kind which we examined, was in the 
following condition: There was a very large quantity of coarse fibrous 
tissue surrounding and enveloping the lobes and lobules of the gland. 
In this there was much irregular fatty deposit, appearing more like 
masses of concrete, fatty matter, than true adipose tissue. The gland- 
tissue was more or less atrophied, not nearly so apparent as natural, the 
ultimate vesicles were not well seen. The epithelium looked coarse- 
grained, and contained much oil. The fatty deposit seemed to have 



532 ABNORMAL CONDITIONS OF THE PANCREAS, ETC. 



taken place in a secondary manner as the result of the shrinking of the 
gland. 

Fatty degeneration of the pancreas is described by Rokitansky as 
frequent in drunkards, associated with fatty liver. It is not, however, 
a degeneration of the same kind, but rather, from this account, seems 
to take place by intrusion of the surrounding adipose tissue on the 
wasting organ. Serous cysts occur occasionally in the pancreas, and 
the other salivary glands. 

Cancer does not select these glands as one of its ordinary sites. It 
does, however, affect them not unfrequently both primarily and second- 
arily. Scirrhus and encephaloid are the only two forms which occur. 
It is probable that, in several of the cases reported as cancer of the 
parotid, the disease was really seated in some of the adjacent or im- 
bedded absorbent glands. The head of the pancreas, where it is em- 
braced by the duodenum, appears to be the part of the organ most 
frequently affected. As a result of the growth of the tumor, the ductus 
choled. sometimes is obstructed, and jaundice is produced. The disease 
may extend much further than this, according to Dr. Walshe, implicat- 
ing u the duodenum, the omentum, mesentery, liver, and even the supra- 
renal capsules and kidneys." Rokitansky says, "that the secondary 
affections of the salivary glands, by an extension of the disease from 
adjoining organs, and in the case of the pancreas especially, by an ex- 
tension from the scirrhous pylorus, is very common. 

Salivary fistulse are usually caused by the progress of ulceration. 
Thus, a perforating ulcer of the stomach may make its way into the 
pancreatic duct, and the same with regard to the duct of Steno, which 
is oftenest perforated. 

Dilatations of the ducts are produced in consequence of obstruction 
of their outlets, while the secretion accumulates and distends the canal. 
The obstruction may depend on an external tumor, 
Fig. 237. or a mucous plug, or on a calcareous concretion. 

Sometimes the dilatation occurs at several separate 
points; sometimes it forms fusiform "or closely- 
set expansions, partially separated from one an- 
other by valvular folds formed by the coats of the 
duct." The salivary concretions, or calculi, are 
salivary calculus of consi- described by Rokitansky as " white, friable, and 

derable size; removed by ope- tit t -i • i t • \ 

ration . either round, oblong, cylindrical, or obovoid ; in 

size varying from that of a millet-seed or pea, to 
even that of a hazel-nut. They are either solitary, or, if small, fre- 
quently very numerous (twenty and more); and they are composed of I 
phosphate and carbonate of lime, held together by animal matter." The 
saliva from which they are formed by deposition, must be, as Dr. Walshe 
remarks, in an unhealthy state ; for while the concretions consist chiefly 
of phosphate of lime, sometimes containing 94 per cent., there exists I 
very little of this salt in the normal secretion. " It becomes, therefore, 
extremely probable that the excess of phosphate is generated through | 
the influence of irritation of mucous membrane." 




ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 533 



ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 

Of the Spleen. — This organ is generally absent in acephalous mon- 
sters ; sometimes it is wanting, together with the stomach, or the fundus 
of the stomach, in subjects otherwise well developed ; or it may be itself 
alone in a rudimentary state. Small supernumerary spleens, which are 
often met with in the vicinity of the organ, are not to be regarded as 
instances of its multiplication, but of its subdivision. The spleen is 
liable to very great variations in size, probably more than any other 
organ of the body. This depends chiefly on the very large size of its 
vascular system, and on the great quantity of yellow, elastic fibre con- 
tained in its structure, which allows it to be distended to a prodigious 
extent. Most, if not all, hypertrophies of the spleen, however, are 
produced not only by engorgement of the vessels, but by an alteration 
and increase of the red, pulpy parenchyma which they traverse. This 
parenchyma consists of nuclei, with granulous matter in small quantity, 
and some slight traces of cell-development. It evidently is not a very 
highly organized substance, like a muscular fibre, and will easily admit 
of increase or diminution. We shall here only mention the degrees of 
change in size which the spleen may undergo. Rokitansky states that 
If the spleen not unfrequently measures sixteen inches in its long, seven 
inches in its short diameter, and four inches in thickness ; its weight may 
amount to 13J lbs.," or even, as others affirm, to 20 lbs. and upwards. 
The opposite change of atrophy may reduce the spleen to the size of a 
hen's egg, or a walnut. The form of the spleen is rather various. It may 
be tongue or platter-shaped, or cylindrical or globular. One of the most 
important circumstances to note under this head, is the great frequency 
of notches in its anterior border, which may be felt through the abdominal 
parietes when the organ is enlarged. The spleen is liable to various 
displacements, some of which are congenital, others the result of disease. 
Haller found it lying by the side of the bladder in a child one year old, 
Desault in the right side of the thorax in a new-born infant. It has 
been found in the left thoracic cavity when the diaphragm was absent, 
and external to the abdomen in large umbilical herniae, or where the 
abdominal parietes were fissured. Displacement may ensue from the 
enlargement or distension of adjacent parts, or from its own increase in 
size. Sometimes in the latter case it descends to, and slides off, the 
ilium, " so as to occupy a diagonal position in the hypogastrium, and 
extend over the right ilium." 

Wounds and Ruptures of the spleen occasionally happen from inju- 
ries or accidents. The only point of interest respecting these is, that 
there appears, from the observations of Mr. Athol Johnson, ground to 
believe that, under careful management, they do not necessarily prove 
fatal. Spontaneous ruptures of the spleen have also occurred in con- 
ditions of intense congestion, and when the texture of the organ was 
probably weakened ; as in typhus, cholera, and the cold stage of ague. 
These always prove fatal. 

With regard to the textural changes in the spleen, Rokitansky re- 
marks " that they almost always arise from certain anomalies of the 



534 ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 

blood, which, though little known, bear a remarkable and positive rela- 
tion to the spleen. The spleen may, in fact, be considered as the most 
sensitive test for a variety of dyscrasic states of the fluids." In this 
we doubt not that there is much truth, and think the view that a cer- 
tain anomalous condition of blood is necessary for the production of 
great enlargement of the spleen is much supported by the circumstance 
that the organ is scarce ever materially enlarged in cases of cirrhosis of 
the liver, when the current through the splenic vein must be so greatly 
impeded. 

Hyperemia of the spleen occurs both from mechanical causes, and 
from that just noticed. Rokitansky remarks that, though it occurs in 
organic diseases of the heart and in hepatic obstructions, it does not 
amount to the extent, nor take place so frequently as might be expected, 
and he accounts for this by the deranged circulating fluid having no 
affinity for the tissue of the spleen. In the bodies of drowned persons 
the spleen is found gorged and distended with blood. This blood, no 
doubt, might all be washed out by injecting the vessels with water, and 
the organ would return to its normal size; but when congestion comes 
to be permanent, the exudation which takes place in the red parenchyma 
becomes organized into similar celloid substance, and the spleen is then 
truly hypertrophied. 

An aiisemic state of the spleen is observed in the highest degree when 
the parenchyma is infiltrated with bacony matter, to be presently no- 
ticed; but it also exists in many atrophied conditions, which very often 
depend on, or coincide with, a development of the nuclei into fibres. 

" Primary inflammation of the spleen," Rokitansky says, "is as rare 
as spontaneous primary phlebitis; secondary, as frequent as secondary 
phlebitis." Primary inflammation of the spleen, unless ending in reso- 
lution, gives rise to an exudation of laudable pus or fibrin. The pus 
may be contained in a circumscribed abscess, and thence become obso- 
lete, or the cavity may go on enlarging until the abscess makes its way 
into the left thoracic cavity, the stomach, the transverse colon, or the 
peritoneum. When the latter event happens, circumscribed peritonitis 
often forms a sac for the pus with the aid of the surrounding parts. 
Secondary splenitis seems to be identical with pynemic deposits, and is 
stated by Rokitansky to consist in nothing more than the (purulent) 
" metamorphosis of an infected coagulum within the channels of a vas- 
cular ganglion." The deposits are well defined, always situated at the 
periphery, usually of a cuneiform shape, the apex directed inwards; 
their color is considerably darker than the surrounding tissue, and their 
consistence firmer. A ring of reactive inflammation is often set up 
around them. The process may terminate either in the case of a be- 
nignant fibrinous exudation in conversion of this into a cellulo-fibrous 
callus, which contracts and causes a cicatrix on the surface; or in the 
case of a less healthy exudation in the conversion of this " into a puri- 
form, creamy mass, or into a sanious, greenish, greenish-brown, or cho- 
colate-colored pulp." Rokitansky notices the frequent occurrence of 
the above affection in " inflammation of the internal vascular coat, and 
particularly" in endocarditis. As he makes no special mention else- 
where of the fibrinous block so common in the splenic parenchyma, we 



ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 535 

conclude" that he comprises it among the phenomena of secondary sple- 
nitis; but we cannot help doubting whether this is correct. To us it 
seems much more probably to be a simple exudation of fibrin, which 
takes place in consequence of the blood being surcharged with this pro- 
duct; and we should regard the simultaneous deposition of fibrin on the 
endocardium of the valves of the heart as a mere coincidence, and not 
in any degree as a cause. M. Simon is inclined to consider that, in 
many cases, disease of the artery leading to the part is the cause of the 
deposit. The appearance of these deposits is that of a circumscribed 
yellowish mass, with a surrounding margin of darker or lighter red 
congestion, of increased consistence, so as to be readily detected on 
handling the part, and exhibiting under the microscope a confused mass 
of granular with more or less oily matter, infiltrated among the remains 
of the parenchyma. They very commonly undergo fatty degeneration, 
and this appears to be the way in which they are removed. 

Among the various enlargements of the spleen more or less connected 
with hyperemia, that occurring in typhus deserves to be noticed. The 
parenchyma, in very marked cases, is exceedingly soft, almost breaks 
up under the hands ; its color is a dirty red, varying from different 
shades of depth to a light chocolate ; its size is greatly increased ; but 
it shows, under the microscope, no very noticeable alteration of its struc- 
tural elements. There may be some increase in the quantity of diffused 
granulous matters ; but the nuclei appear quite natural. The change is 
one better judged of on a large than on a small scale. We have ex- 
amined, at different times, numerous specimens of greatly enlarged 
spleen, but we have found little that could be regarded as characteristic 
of the several alterations. This is not surprising ; it could not be ex- 
pected that specific differences in the blood should mark themselves by 
corresponding varieties of form in the cell-growths of their exudations, 
any more than that the syphilitic virus should be detected by some spe- 
cial modification of the pus of a chancre. 

In a case of Leucocythemia, recorded by Dr. Chambers in the Report 
of the Pathological Society for 1846-47, it is stated that the spleen, 
which measured 14 inches by 4 or 5, was extremely dense, "exhibiting 
on a section a beautiful mottled appearance ; but under the microscope 
presenting no obvious deviation from the normal character. In a similar 
case we noted that the nuclei of the parenchyma were more granular 
than usual, and were often in process of cell-development, but the same 
change often occurs in other diseases. In a man dying with ulcerations 
of the colon, producing excessive diarrhoea, and who had formerly passed 
large quantities of lithic acid, the greatly enlarged spleen presented a 
perfectly uniform smooth surface, of a rather light red color, and exhi- 
bited under the microscope no peculiarity of structure, except that, 
together with the normal elements, there were mingled numerous largish 
crystals, probably those of triple phosphate. In a female dying with 
cancerous growths in the fauces and in the lungs, the spleen was so 
enlarged as to weigh four pounds twelve ounces. Its cut surface exhi- 
bited an irregularly raised appearance, being formed of elevations of a 
dull whitish color, with intervening red streaks. The whitish elevations 
consisted of pale, colorless, nuclear corpuscles, closely resembling the 



536 ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 

normal corpuscles of the Malpighian bodies. The red parenchyma had 
almost disappeared, there were only a few vessels seen running between 
the hypertrophied Malpighian masses. There was a considerable amount 
of black pigment deposited in the course of the vessels, and some crys- 
tals, like those seen in the former case, were also present. The exami- 
nation of these two specimens seem to warrant the conclusion that, in 
the former, the red parenchyma was the seat of the hypertrophy, the 
Malpighian corpuscles in the latter. The two following instances seem 
to be examples of the infiltration of the splenic parenchyma with fibrinous 
matter, rather than of a true^hypertrophy of it like the preceding. It 
is especially to be observed that they were general, and not confined to 
one part of the viscus. Dr. Ogle has recorded, in the Report of the 
Pathological Society for 1851-52, the case of a man who died with 
pleurisy in connection with granular degeneration of the kidneys. The 
spleen weighed seventeen ounces, and was of firm, solid texture through- 
out. " In its substance were three or four large patches of a yellowish- 
colored deposit, having a slightly pink hue towards their central parts. 
These existed at the peripheral portions of the viscus, and penetrated 
to some extent into the interior. Moreover, the whole viscus was of a 
mottled color, owing to an extensive infiltration of a lightish-colored 
material, which gave to it its firm, unyielding character. Examined by 
the microscope, the deposits proved to consist of amorphous and granu- 
lar matter, larger fatty granules, with great numbers of small, oval, and 
elongated cells, having a nuclear appearance, along with an admixture 
of what seemed to be the natural cells of the organ. No indications of 
ulterior development or organization existed in the deposit. The invest- 
ing fibrous capsule of the spleen was thickened and rendered opaque, 
having several tough bands of false membrane attaching it to contiguous 
parts ;" and the lining of the splenic artery contained atheromic deposit. 
In the following case, a similar deposit had taken place both in the liver 
and spleen, giving to both organs a great increase of firmness and tough- 
ness. The cells of the liver were almost entirely destroyed, and replaced 
by a fibroid tissue containing in its substance numerous nuclear and cel- 
loid particles. The spleen weighed three pounds six ounces, and mea- 
sured fifteen inches by ten and a half; it was very bloodless, but its 
arteries appeared healthy, though the aorta was highly atheromatous. 
The cut surface of the organ had a peculiar gray, uniform aspect, with 
some small red specks and dots scattered over it. Under the microscope 
it showed a granular, homogeneous basis, having a slight tendency to 
fibrillate, with numerous nuclear corpuscles and much oily matter dis- 
persed through it. The nuclear corpuscles resembled exactly those of 
the healthy organ. In a third form of chronic enlargement of the spleen 
the character of the alteration is distinctly marked by the presence of 
a peculiar form of deposit which is described by the terms lardaceous 
and bacony. It often exists at the same time in the liver and kidneys, 
and always appears in connection with a lowered condition of the organic 
power. It appears, under the microscope, as irregular fragmentary 
masses, homogeneous, translucent, and sub-refracting, mingled commonly 
with more or less of the structural elements of the part in which it is 
deposited. It has appeared to us sometimes to be deposited in the situa- 



ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 537 

tion of the Corpora Malpig., so that there are seen spots or circular 
spaces which are separated from each other by the remains of the paren- 
chyma. The organ is often much enlarged, is remarkably bloodless 
when extensively invaded by the deposit, and at the same time is brittle, 
and gives a peculiar resinoid fracture. We may recapitulate the fore- 
going account of chronic enlargements of the spleen, by enumerating 
them as resulting from (a) true hypertrophy, (b) infiltration with fibrin- 
ous deposit, (c) a condition compounded of hypertrophy and infiltration, 
and (d) deposition of lardaceous matter. Rokitansky states that many 
cases of splenic enlargement " depend upon the formation of certain 
corpuscles, in addition to the existing hyperemia." He denies that 
these corpuscles are identical with the Malpighian, but his own descrip- 
tion of them shows that they are very similar ; and as we know, from 
our own examinations, that these do occasionally exist, we are much 
inclined to believe that those to which Rokitansky refers are no other. 

The fibrous capsule of the spleen is very frequently the seat of 
chronic fibroid thickening, which sometimes proceeds to a very great 
extent. The thickened membrane has much the 
aspect of cartilage, but none of its real characters. Fi g- 238 - 

Usually, the thickening extends pretty uniformly 
over the surface, leaving, however, here and there, 
spots less affected; sometimes it forms nodular 
masses grouped together. In one case we ex- 
amined carefully, it was very apparent that the 
thickening had taken place on the inner surface of 
the capsule, at the expense of the parenchyma, and y^oid thickening of cap- 

L . _/ 1 i • i l • n l sule, encroaching on the 

we are inclined to think this is generally the case, dark parenchyma, vertical 

Certainly, the process is distinct from the formation section. 

of bands of adhesion to adjacent parts. Fibroid 

tumors of the parenchyma are rare. Ossification of the thickened 

fibroid layers takes place rarely, except in very old persons. Fibrinous 

deposits in the parenchyma may, together with other alterations, cretify. 

Phlebolithes may form in the venous channels. 

Tuberculous matter is, for the most part, deposited in the spleen only 
in acute universal tuberculosis; it occurs more frequently in children 
than in adults, in the proportion of 40 : 13. It appears both in the 
form of gray granulations, miliary crude tubercles, or yellowish cheesy 
masses, of the size of a pea and above. In acute tuberculosis, the spleen 
is described by Rokitansky as becoming swollen and softened, much as 
in the typhous state. The organ was much enlarged in the last case we 
witnessed, but it was distinctly observable that there was no congestion 
around the tubercles. Their substance consisted of an amorpho-granulous 
matter imbedding oily molecules and freely-formed nuclei. Rokitansky 
notices the formation of a pseudo-cyst round tubercles, and the not un- 
frequent presence of a small central cavity in their interior. 

We have occasionally observed small cysts in the spleen, or, perhaps, 
to speak more accurately, in its capsule; in a female of mid age dying 
with fever, there were several small, firm, nodular prominences on the 
anterior border; they were of conical shape and lightish red color, ap- 
pearing like so many growths on the surface; under the microscope, they 




538 



OF THE THYROID GLAND. 
Fig. 239. 




Masses of crude tubercle in spleen. 



were found to be small cyst-like cavities of varying size (one measured 
g 1 ^ inch diameter), oval or spherical, containing numerous large granule- 
cells floating in a transparent liquid. 



Fig. 240. 




Cyst in the capsule of the spleen, containing a clear fluid and glomeruli. 

Hydatid cysts are sometimes found in the spleen alone, or concur- 
rently "with one in the liver; it rarely attains the size it reaches in the 
latter organ." Dr. Coley exhibited to the Pathological Society a speci- 
men of the magnitude of a cocoa-nut. 

Cancer is rare in the spleen, the only form which it assumes is en- 
cephaloid, and this is very rarely, if ever, solitary ; it occurs associated 
with similar disease of the liver, stomach, and omentum. 



OF THE THYROID GLAND 



We are not acquainted with any instance of excessive congenital de- 
velopment of this gland, unless the rare occurrence of simple hypertrophy 
should be regarded as such. Mr. Curling has recorded in the Medico- 
Chirurgical Transactions, two instances of its absence in idiots. The 
most complete account of its morbid alterations is that given by Professor 



OF THE THYROID GLAND. 



539 



Hasse, from which we shall extract the greater part of the following 
summary: " Inflammation of the thyroid is rare. It may attack the 
organ, either when healthy or when enlarged by previous disease. Its 
course is more frequently chronic than acute. Within a very brief 
interval the gland often swells considerably — becomes very bloodshot, 
tense, and painful — its texture softened and friable, assuming first a 
brown-red, and ultimately a dingy-gray color." When suppuration 
occurs, there may be several foci, or one large one involving the whole 
gland. The abscess may open externally, or into the oesophagus, or 
into the trachea. After this has occurred, the gland on the side affected 
shrivels "into a hard, cellular, filamentous knot, which adheres firmly 
to the skin and the surrounding parts. Sometimes the shrivelling of 
the one gradually brings on wasting of the other lobe." Andral states 
that acute tumefaction of the thyroid may come on after violent exertion. 
Simple enlargement of the thyroid is frequent, says Hasse, and for 
the most part inconsiderable; but it implicates the entire gland, and 
thus may cause greater disturbance than a more extensive tumor of 
another kind. " Both lobes of the gland, and even the middle one, swell 
so as to encroach equally on each side, against the trachea and vessels 
of the neck." The affection is almost wholly confined to youth, and is 
frequent about the age of puberty in both sexes — more so, however, in 
the female, in whom enlargement is especially apt to prevail at the 
approach of the menstrual period. The essence of simple hypertrophy 



Fig. 241. 



Fig. 242. 





Bronchocele, from the King's College col- 
lection. The oesophagus is seen to be 
pushed to the right side by the tumor. 



Section of a bronchocele. showing calcareous de- 
From the Middlesex Hospital Museum. 



seems to be the derangement of the equilibrium naturally existing between 
the processes of secretion and absorption, that continually go on in 
the gland. When the former predominates, the vesicles, and of course 
the whole organ, become distended. M. Coindet relates that a regiment 
of young recruits were almost all attacked by considerable enlargement 
of the thyroid, shortly after their arrival at Geneva. On changing their 



5-iO OF THE THYROID GLAND. 

habitation, and the water which they used for drink, they all quickly 
recovered. In this instance, and in a multitude of similar ones, it seems 
beyond doubt that some constituent of the water being absorbed into the 
blood, acted as a stimulus to excessive secretion into the thyroideal 
cavities. The effect produced would be quite analogous to that of a 
diuretic salt. In the chronic and permanent enlargements of the thyroid, 
a more considerable amount of change takes place. The vesicles of the 
gland are not only distended by excess of their natural secretion, but, 
besides being greatly enlarged, are filled with calcareous, atheromatous, 
and other matters. It is probable that some new vesicles are formed, 
as well as old ones enlarged. Hasse makes two separate varieties of 
melicerous degeneration and cystic formation ; but we think they run so 
much into one another that they may be classed together. In the pure 
melicerous degeneration, the secretion which distends the vesicles, and 
some of them much more than others, is a tenacious, viscous, jelly-like 
substance, of the color of honey. The vessels seem to be usually com- 
pressed, so that the gland appears bloodless. The change is sometimes 
limited to certain portions, an interesting instance of the power which 
the vitality of each individual elementary part has in determining the 
character of its actions. In the more common cases of enlarged thyroid, 
the vesicles contain, besides colloid matter, more or less inspissated or 
fluid, varying quantities of calcareous, often ossiform substance. We 
have seen crystals approaching the octohedral form in the contents of 
the cavities, as well as tablets of cholesterin ; and fatty matter seems to 
be not unfrequently present, probably as the result of fatty degeneration. 
An instance related by Dr. Haen, shows the great variety of appearance 
which the contents of the cysts may present. He says that, in a fright- 
fully enlarged thyroid, he found almost every variety of tumor existing 
together. " Here was a steatoma, there an atheroma ; in another place 
a purulent tumor; in another, an hydatid; in one, there was coagulated, 
in another, fluid blood; on this side was a loculus full of glutinous matter; 
on that, was one filled with calcareous matter, mingled with tallow." 
One of the cystic cavities sometimes enlarges prodigiously at the expense 
of the others; Andral relates having found a thyroid transformed into 
a cyst with bony walls, filled with a honey-like matter. Another kind 
of enlargement of the thyroid, consists in the dilatation of its vessels, 
constituting what is called vascular or aneurismatic bronchocele. The 
veins in particular, writes Hasse, form very dense, capacious, often 
knotted plexuses, and the whole texture consists, apparently, of a dense 
coil of vessels. The substance of the gland has almost entirely lost its 
granular character — it is flabby and dark-red. After death, the tumor 
collapses considerably. The walls of the arteries and veins are attenu- 
ated; the dilated membranes of the vessels contain considerable clots, 
and capacious cavities are found, filled with black coagulated blood. 
In a remarkable specimen, which seemed in part to belong to the above 
class, we found the greatly dilated vessels completely coated with oily 
matter, so as in some parts to appear like white cylinders by direct light. 
At the same time, the glandular vesicles were destroyed, and only some 
traces of their epithelium could be discovered. This, which would 
certainly be the most important feature of the alteration, is not directly 



SUPRA-RENAL CAPSULES. 54:1 

stated by Hasse to take place in the above description, though it seems 
inferable from the statement, that the granular (vesicular) character of 
the gland is almost entirely lost. We have observed in a second ease, 
the same destruction of the glandular structure, and dilatation and oily 
incrustation of the vessels, but there was a more considerable deposit of 
earthy matter. Tuberculous deposit is rarely if ever found in the 
thyroid. Cancerous disease is also very rare, but has been observed 
both in the forms of scirrhus and encephaloid. "When primary, the 
disease is usually of the infiltrated form; when secondary, of the tube- 
rous." Encephaloid growths sometimes attain such a degree of vascu- 
larity, that they resemble fungus baematodes. 

Of the thymus. — Absence of the thymus has only been obsei-ved in 
cases of acephalism. Inflammation is an exceedingly rare occurrence; 
but Hasse refers to two cases, in one of which an abscess is said to have 
opened into the trachea. In cases of tuberculosis the thymus is occa- 
sionally involved; it becomes considerably enlarged, "firmly united with 
surrounding parts, and either converted by tubercular infiltration into a 
hardened mass, or else partially destroyed by softening." Mr. Simon 
mentions a case in which suffocation was occasioned by the pressure of 
a tumor apparently of sarcoma to-cystic character, in the situation of 
the thymus; and Sir Astley Cooper met with a case of encephaloid 
growth in this part. The thymus is not unfrequently found greatly 
enlarged; but the nature of the hypertrophy, as it is called, has not 
been exactly determined by microscopic observation. It is tolerably 
certain that this enlargement is not, as has been supposed, the cause of 
attacks of sudden and sometimes fatal dyspnoea occurring in children. 
For it has been shown that "thymic asthma," as it is termed may occur 
with an unnaturally small thymus ; and that the gland may be greatly 
increased in size without producing any symptoms of dyspnoea. 

Of the supra-renal capsules. — We take the following brief account 
in part from Rokitansky. The supra-renal capsules may be deficient, 
especially where there is a deficiency in other organs also. Their ab- 
sence, however, does not coincide with that of any other organ in parti- 
cular, and they may be present when one kidney is absent, so that their 
name must not be taken to imply any correlation of function. Accessory 
supra-renal capsules are of frequent occurrence. They are sometimes 
found hypertrophied, but the nature of the enlargement does not appear. 
Their normal condition is one of at least relative atrophy, that is, they 
do not grow and increase in size together with the other parts of the 
body. Their most usual condition, according to numerous examinations 
that we have made, is the following: On making a transverse section, 
there is seen a cortical layer of a whity-gray or yellowish color, often 
markedly striated, and consisting of cells, more or less laden with oily 
matter, and arranged in very perfect rows. Within the cortical, and 
usually not occupying more than one-third of the whole diameter, is the 
medullary, traversed by the central vein or its branches. This is of a 
pale opaline, often dark-red color, and consists of large nuclei set in a 
granulous basis, containing very little oil. There is often much yellow- 
ish pigment in the cells of the cortex where it adjoins the medullary 
portion ; these cells resemble very much those of the liver when laden 



5±2 SUPRA-RENAL CAPSULES. 

with yellow matter. The principal indications of atrophy are mani- 
fested, we think, by the shrinking and diminution of the medullary sub- 
stance, and the breaking up of the cortical cells into oily masses. It is 
interesting to compare the condition of the degenerating capsule with 
that of an hepatic lobule. In one instance, where a careful search was 
made, at our request, for the supra-renal capsules in the body of a child 
six years old, who had died from a burn, no trace of them could be found; 
but a small quantity of lax, dirty-looking, reddish, infiltrated, areolar 
tissue, which presented under the microscope only a mixture of altered 
granulous nuclei, large granulous or oil-holding cells, and a very large 
quantity of diffused granulous matter imbedding some oil-drops. This 
was a case of unusually early atrophy. Another indication of atrophy 
is afforded by the formation of a central cavity, which exists in some 
cases quite distinct from that of the vein. It is formed, we believe, by 
the wasting of the medullary substance, and the production thereby of 
a space which is traversed by bloodvessels, and occupied only by serum, 
and a little stromal fibre. In this way a lax spongy tissue is first formed, 
which often is stained of a dark maroon or bistre color, by exuding and 
altered hsematin. This tissue is afterwards absorbed, and a cavity with 
more or less smooth walls is thus produced. Rokitansky says: "Hemor- 
rhage not unfrequently occurs in them, on account of the vascularity of 
their medullary substance. The capsule is found distended in propor- 
tion to the amount of extravasation caused by the rupture of a vein; 
and according to the period which has elapsed since the occurrence of 
hemorrhage, we find the blood more or less discolored and changed in 
constitution, inclosed within the cortical substance, which has become 
pale and atrophied, and is finally converted into a fibroid layer. Sup- 
puration and induration are occasionally met with as results of inflam- 
mation of these glands. They have been found converted into purulent 
pouches in the new-born child, and in the foetus. " Tubercle commonly 
appears in the supra-renal capsules in large masses, and either fuses 
into pus, inclosed in a callous sac, or is converted into a chalky concre- 
tion invested by a fibroid tissue." Cancer in the form of encephaloid 
occasionally attacks the supra-renal capsule, according to Dr. Walshe 
and M. Roger, only as secondary to disease of the kidney, or (on the 
right side) of the liver. It causes considerable enlargement, and when 
hemorrhage takes place the mass may be broken down into a chocolate- 
colored pulp. 



MORBID ANATOMY OF THE URINARY 
APPARATUS. 



CHAPTER XXXV. 

Congenital Anomalies. — The kidneys are very rarely absent entirely ; 
but it is not uncommon to find one only. In this case, Rokitansky 
makes a distinction between the unsymmetrical and the solitary kidney. 
The former has its usual position and shape, and is only larger than 
natural. The solitary kidney is produced by the more or less complete 
fusion of the two organs together; in its lowest degree it constitutes 
the horseshoe kidney, the lower parts of each being connected by a band 
of renal substance passing across the vertebral column. In the highest 
degree, there is only a single disk-like kidney, lying in the median line, 
and situated much lower down, at the promontory, or in the concavity 
of the sacrum. 

Hypersemia. — This condition of the kidney is of frequent occurrence, 
but is almost always the result of some prior general affection, as of 
obstructive disease of the heart, the scarlatinal poison, or the arrest of 
the cutaneous transpiration. We shall describe an extreme case, to 
convey an idea of the state of congestion that may often be inferred on 
good ground to exist, and shall hereafter refer to it as the commence- 
ment of other affections. The kidney is enlarged, its weight often 
doubled; it is of dark-red color, and drips with blood when cut into. 
The cortical substance, the medullary cones, the mucous lining of the 
calyces and pelvis, are all much congested. The former is somewhat 
softened, of a dark-red color, and presents in many cases small dark- 
red spots, which are the result of hemorrhage into and between the 
tubes. The Malpighian tufts are also distinctly seen as minute, reddish, 
subtransparent grains, prominent on the cut surface. In the medullary 
cones, the congested vessels form long dark-red streaks. A somewhat 
turbid sanguineous fluid is contained in the injected calyces and pelvis. 
The capsule, if the hyperemia has befallen a healthy kidney, can be 
peeled off readily. Microscopy shows the Malpighian and other capil- 
laries loaded with blood, extravasation sometimes into the capsule of the 
former, and often into the channel of the tubes. In a typical case, no 
other alteration would be visible ; but it is scarcely conceivable that the 
hyperemia should proceed to any great degree without exudation of 
fibrinous fluid taking place, which is then seen, having coagulated in the 



5-i-t HYPEREMIA. 

tubes, forming casts of their interior, and consisting of a granular or 
homogeneous material entangling blood-globules, and often some de- 
tached particles of epithelium. In one case, where we observed the rise 
of hyperemia almost from its commencement, and which was further 

Fig. 243. Fig. 244. 





Hemorrhage into Malpighian capsules compressing Tube containing some yellow granules, 

the tufts. the remains of extravasated blood. 

peculiar, in that there was no manifest exciting cause, the fibrinous 
exudation appeared as extremely pale-reddish, granular films, entangling 
some renal epithelium ; subsequently, casts were observed, and blood- 
globules. The gradual nature of the commencing effusion was probably 
the cause that the fibrin did not coagulate at once in the cavity of the 
tubes. Congestion, then, often reaching an extreme degree, early giving 
rise to fibrinous exudation, and in many more advanced cases to hemor- 
rhage, and an otherwise sound state of the renal tissue, are the prin- 
cipal features of hyperemia. 

We may here notice somewhat further the circumstance of renal 
hemorrhage. It may occur as an endemic, and, to judge from the ab- 
sence of bad effects, scarcely serious phenomenon. Dr. Prout remarked 
its prevalence during the period first subsequent to that in which the 
cholera prevailed; it was uninfluenced by remedies, and after some 
weeks ceased of its own accord, and without leaving any unfavorable 
result. Turpentine and cantharides have not unfrequently caused renal 
hemorrhage; they act as irritants upon the organ, and produce a state 
of congestion. Malignant fevers, purpura, and scurvy, are not uncom- 
monly attended with hematuria, and there is good reason to believe 
that in most cases the blood comes from the kidney. In some of these 
affections, characterized by a fluid condition of the blood, the casts of 
the tubes would probably be absent, or very imperfectly formed. Blows 
on the loins are another cause of renal hemorrhage. In an interesting 
case recorded by Dr. Johnson, the bleeding recurred several times, the 
blood coagulating in the tubes, and forming casts which appeared in the 
urine. A calculus lodged in the calyces or pelvis of the kidney is often 
the cause of hemorrhage, which, though taking place from the kidney, 
and perhaps being very abundant, is distinguishable from the preceding 
forms, as well shown by Dr. Johnson, by the circumstance that there 
are no casts of the tubes. These cannot be formed ; as the blood, not 
being effused from the renal tissue, but from the mucous membrane, 



NEPHRITIS. 545 

does not traverse their channels. 1 Cancerous disease of the kidney is 
sometimes attended with bleeding, but this can scarcely be distinguished 
from that which is the result of the irritation of a calculus. Blood 
globules, when retained in the tubes, sometimes undergo change into 
small yellow corpuscles, very much like those which are often found in 
the spleen. It is necessary to be aware of this circumstance, as other- 
wise the observer might suppose that biliary matter was present. 

Ansemia. — General anaemia does not seem to affect particularly the 
condition of the kidney, at least, we have notes of one case of extreme 
anaemia, the result of menorrhagia, and which at last terminated fatally, 
in which, although the kidneys were small, the epithelium of the tubes 
was very perfectly formed. Mr. Simon notices, however, a condition 
of atrophy of the epithelium, resulting from the obstruction of an arte- 
rial branch by atheromatous and fibrinous matter, which would of course 
produce a local anaemia. In that which is regarded by several as the 
second stage of renal degeneration, the kidney, though much enlarged, 
is often remarkably pale. This anaemia, however, is not attended with 
atrophy, and is itself, probably, in part the result of pressure exercised 
on the intertubular plexus. 

Nephritis, analogous to common inflammation of other parts, and like 
it often passing into suppuration, is not a very common disease. It is 
most frequently seen as the result of the irritation of calculi in the kid- 
ney, or of inflammation of the bladder, which has either spread up along 
the ureters, or directly attacked the kidney. Blows on the loins are 
also mentioned by Drs. Prout and Johnson, as causes of nephritis. The 
latter also believes that a morbid state of the blood, such as gives rise 
to carbuncles, may act in this way. Rokitansky speaks of nephritis 
following acute or chronic diseases, and presenting a type corresponding 
to the general dyscrasia. Whatever be the cause, the general characters 
of the inflammatory action will not differ materially, provided it is true 
nephritis that we are dealing with, and that it passes on to the stage of 
suppuration. Nephritis, unattended with the formation of pus, would 
probably be undistinguishable from the condition of hyperaemia above 
described. In a man, who died in St. Mary's with an enormously- 
thickened bladder and inflamed kidneys, the bladder being the original 
seat of disease, and the kidneys secondarily involved, we found the latter 
organs in the following condition. They were very greatly enlarged, 
and in some parts very much injected; in others, the red surface had 
numerous whitish spots, or patches, appearing through it; these were 
seen in sections to be the ends of long striae, which commenced at the 
base of the medullary cones, and extended to the surface of the organ. 
Between them were interposed streaks of congestion. There was nothing 
remarkable in the medullary cones, except that they had a coarse aspect. 
Microscopy showed that the cortical tubes were quite infarcted with 
their epithelium; in the whitish portions this was especially accumulated, 
and altered so that it resembled a mass of nuclear particles ; the tubes 
also were not clearly seen ; they were doubtless so distended and crowded 

1 In a case of chylous urine, now under Dr. Chambers in St. Mary's Hospital, a large 
quantity of blood as well as fibrin conies away in the urine, but there are no casts. 

35 



546 NEPHRITIS. 

together that their outlines were lost. In some parts the basement- 
membrane of the tubes was gone, and the contents appeared as a naked 
strand of nuclei and granular matter, part of which became dispersed 
between the tubes, and made the mass quite uniform. This mass of 
altered renal structure was evidently on the point of fusing down into 
fluid pus. The Malpighian tufts appeared healthy. The medullary 
tubes were also infarcted, some of them very much, and were opaque, as 
if containing finely-divided oily matter. There seemed to have occurred 
also an extra-tubular effusion of plasma, solidifying into a granular stuff. 
Dr. Johnson, in narrating a case of suppurative nephritis, says, " that 
the appearances in the kidneys showed the transition from epithelial 
cells to pus-corpuscles ; some tubes being filled with desquamated epi- 
thelium, others with pus, while in other parts the pus-cells had accumu- 
lated so much as to destroy all trace of tubular structure." The urine 
in these cases is found to contain cylindrical masses of pus-cells, which 
have evidently been formed in the renal tubes ; this sign, while it lasts, 
serves to distinguish suppuration in the kidney from that taking place 
in the bladder, as in the latter case the pus-corpuscles form only shape- 
less masses. When the suppurating renal tissue is quite broken down, 
the pus will no longer form casts, the tubes being destroyed. Rokitan- 
sky remarks, that enlarging renal abscesses are bordered by a red in- 
jected halo, which gives rise to a fusible product, leading to an extension 
of the abscess. They are always more numerous in the cortical sub- 
stance, and generally of a roundish shape, while in the tubular substance 
they are more elongated, like strise. The mucous membrane of the 
calices and pelvis, especially when a calculus is lodged in these cavities, 
is softened and inflamed, and secretes a purulent fluid. The extension 
of renal abscesses may go on until the whole organ is converted into a 
mere pouch of pus ; in this case, or even before the organ is quite de- 
stroyed, the abscess may make its way by the usual process of absorp- 
tion, penetrating through surrounding indurated tissue, and evacuate its 
contents in either of the following situations: (1) Externally into the 
lumbar region; (2) into the cavity of the peritoneum ; (3) into the as- 
cending or descending colon, or into the duodenum; (4) into the bronchi 
after perforation of the diaphragm. Acute inflammation of the kidney 
may become chronic, or the inflammation may have a chronic character 
from the outset; its results may be suppuration or induration, and con- 
secutive atrophy of the organ. Dr. Watson thinks that nephritis, con- 
fined to the parenchymatous substance, may arise and pass through all 
its stages without announcing itself by marked local signs, such as pain, 
&c. This would give the process, though truly acute, an appearance of 
being chronic. It seems desirable to notice the possible simulation of 
an abscess by a mass of softened fibrinous exudation, which may be bor- 
dered by a red halo as in abscess ; the microscope would sufficiently dis- 
tinguish the one from the other. 1 

1 We have recently witnessed a very interesting case of fibrinous deposit in the kid- 
neys ; in which cavities were formed, closely resembling abscesses. A youth, set. 20, 
sulfered with symptoms of fever Avith pus, mucus, and blood in his urine for nine days, at 
the end of which time he died. The bladder was empty and contracted, and only pre- 
sented some ecchymosed spots ; the left kidney contained several small spots of softening 



DEGENERATIVE DISEASE OF THE KIDNEY. 547 

Degenerative disease of the kidney. Morbus Brightii. Desquamative 
and non- desquamative nephritis. Subacute inflammation of the kid- 
ne y t — These names refer to an extremely common and important disease 

Fig. 245. 




Fibrinous deposits in a granular kidney. The situation of the patch is marked by the irregular outline? 

which was a deep red. 

of the kidney, -whose main features were discovered by Dr. Bright, but 
whose real nature is still a matter of doubt. In calling it a degenerative 
disease, we have expressed our own opinion respecting it, which coincides 
very closely with that held by the late Dr. Prout. Our brief limits for- 
bid any detailed discussion, and we shall therefore simply endeavor, first, 
to describe the morbid alterations which seem to belong to this disease, 
and then to give some account of its pathology and nature. A kidney 
in the state of hypersemia, which we have above described, or somewhat 
approaching to it, with fibrinous exudation in the tubes, is considered 
by Frerichs as in the first stage of Bright's disease : we greatly doubt 
if this is generally the case, and cannot look upon hyperemia as a 
necessary element in the morbid process. Dr. Johnson considers the 
same condition as the result of acute desquamative nephritis, and be- 
lieves that complete recovery may not unfrequently take place. In this 
we quite agree with him, and so, we think, would most observers. He 
differs, therefore, from Frerichs, in not considering the hypersemic con- 
dition as constituting the first stage of Bright's disease. The urine 
produced by kidneys in this state is very characteristic ; it is of a 
rather deep, smoky-red color, with a copious dark-reddish deposit, con- 
sisting of blood-corpuscles, renal epithelium, and fibrinous casts entang- 
ling more or less of the latter. Sometimes corpuscles are present which 
resemble those of pus, and like them have compound nuclei. The 

fibrin, the right many large ones, several of which had broken down, and given rise to 
cavities with ragged and slonghy walls. There was no manifest trace of inflammation 
of the other parts of the kidney ; the microscope showed the tubes in a tolerably healthy 
state. This seems to have been a case of fibrinous deposit confined to the kidneys ; ft 
was remarkable that though the kidneys themselves were uninflamed, inflammation had 
been excited in the peritoneum by the disorganizing processes taking place in the right. 



548 



DEGENERATIVE DISEASE OF THE KIDNEY. 



appearance of this deposit will be best understood by reference to the 
accompanying figure. The hsematin of the blood-globules exudes from 
them, and gives the peculiar red color to the urine, which is at the same 
time scanty and loaded with albumen. It will be manifest that an op- 
portunity rarely occurs of examining kidneys during the existence of the 
intensity of the hyperaemia, as this has generally subsided, or been 
removed, before the disease proves fatal ; the observer, therefore, must 

Fig. 246. 







%ti& 4, 



Drawing of red deposit from urine in intense renal hyperemia. 

not be surprised at finding kidneys, which he supposed to have been 
recently in a state of great congestion, without much appearance of it : 
the hyperemia will, of course, decline, in proportion as it is relieved by 
the hemorrhagic effusion, or by treatment, and the urine, at the same 
time, will begin to increase in quantity, to lose its red color, and to 
contain a less amount of albumen. The effusion of serum, with a certain 
quantity of fibrinous matter, continues for some time after the hemor- 
rhage has ceased, so that casts of the tubes, which become, however, 
more delicate and pale, traces of renal epithelium and albumen are still 
discoverable in the urine, until recovery is complete. Crystals of uric 
acid, in considerable quantity, are also often present during conva- 
lescence, and we have also seen oxalate of lime. These may be viewed 
as indications that the organ is recovering its lost power. 

We have thus noticed the hypersemic or acute inflammatory disease of 
the kidney, because, though not believing it ourselves to belong to the 
truly degenerative processes, it produces symptoms in some measure 
similar, and is regarded by one of the best authorities as always taking 
the initiative in a more or less marked manner. It may, of course, 
give rise to a true degeneration, and apparently-pass into it ; but there 
is not more connection, we believe, between the two, than between an 
attack of bronchitis and succeeding pulmonary phthisis. In the first 
form of renal disease which appears to us truly degenerative, the kidney 
is considerably enlarged, even more sometimes than in acute hyperemia ; 
it is generally pale, sometimes of an opaque grayish-white, with mottling 



DEGENEKATIVE DISEASE OF THE KIDNEY. 549 

spots or streaks of red ; its capsule peels off readily ; the surface is 
smooth and tolerably uniform, or presents opaque spots, indicating the 
site of future granulations ; or these, again, may be just beginning to 

Fig. 247. 




(a) Tube containing an homogeneous cast, which projects from its broken end. (b) Malpighian body ; the 
capsule is filled with oily matter. 

become prominent. The surface of a section shows the thickness of the 
cortical substance much increased, and the medullary cones also some- 
what enlarged and markedly striated, so as to resemble a plume of 
feathers ; they are usually more congested than the cortex. The renal 
tissue in the latter part appears to be obscured or confused, as if some 
coagulating fluid had been effused throughout it; it is commonly marked 
also by similar indications of commencing granulations to those which 
are seen on the capsular surface. The mucous membrane of the calices 
and pelvis is somewhat swollen and reddened. The consistence of the 
kidney is rather diminished ; it is rather flabby and soft. The above 
description applies to many instances of an early degenerative condition ; 
but there are many others also, in an early stage, which differ in several 
respects. The size of the organ may not be materially increased, though 
its structure is evidently altered ; its consistence may be dense, firm, 
and brittle, instead of soft and flabby ; its capsule may be firmly ad- 
herent, and its color more approaching the natural. Cysts are some- 
times observable on the surface of the organ, but this is no necessary 
part of the morbid change. When thin sections are examined micro- 
scopically, the following circumstances are observed: The epithelium 
lining the cortical tubuli is greatly increased in bulk; sometimes 
its particles are more completely formed than usual, and appear 
more distinct and separate ; sometimes their size is greatly exaggerated, 
so that a few particles cohering together form a large bulky mass ; 
sometimes the tube is filled with a melange of stunted or withered- 
looking nuclei, granular matter, and ill-formed celloid particles. The 
central channel of the tube, which should, normally, be about one-third 
or one-fourth the whole diameter, is much encroached on and even 
obstructed by this accumulation of epithelium ; from the same cause, 



550 



DEGENERATIVE DISEASE OF THE KIDNEY. 



the tube becomes dilated, and hence the bulk of the organ is increased. 
Coagula of fibrin also are present in some of the tubes, but not in the 
great majority, and doubtless aid in increasing the obstruction. The 

Fig. 248. 




s i vj 



(2) Cortical tube, infarcted with epithelium, and bulged in a good part of its extent. (3) Cortical tube 
containing a dumb-bell crystal of large size. (4) Cortical tube, infarcted by epithelium at (a) below it ; some 
of the separate particles are shown more highly magnified. (5) Bulky epithelium from cortical tube ; the 
group at (a) are remarkably enlarged, those below them are more or less fatty. (6) Medullary tube much 
infarcted; the contents are seen escaping from the upper end. 



Fig. 249. 




(a) Cortical tubes, containing a very fatty epithelium, (b) A short homogeneous cast, containing two 
corpuscles, (c) Portion of a medullary tube, containing three casts, looking much like cysts and oily matter. 

The four preceding figures are intended to illustrate the changes observed in the enlarged form of degene- 
rated kidney. 



PEGENEEATIVE DISEASE OF THE KIDNEY. 551 

basement-membrane of the tube, in some cases, is natural, in some is 
decidedly atrophied, and scarcely can be detected. A condition of the 
epithelium is sometimes observed which is extremely significant, we 




Microscopic view of epithelium-cells and fibrinous shreds from the tubuli uriniferi of a kidney affected with 
Bright's disease. (1) Epithelium-cells from the tubuli uriniferi, loaded with oil-globules, magnified 400 
diameters. (2) Fibrinous shreds from their interior, having blood- corpuscles and oil-globules entangled in 
them, magnified 200 diameters. (3) One of the tubuli from a kidney affected with Bright's disease. Oil- 
globules are seen through its walls. 

think, of the nature of the morbid process ; it is noticed by Dr. Johnson 
as peculiar to that form of disease which he denominates non-desqua- 
mative nephritis. The epithelium in this does not accumulate and block 
up the tubes, but appears as a coarsely granular opaque stratum, of the 
natural width, resting on the basement-membrane. 

The Malpighian tufts are more opaque than natural, the capillaries 
being obscured by a film of coagulated fibrin ; in some cases this is so 
abundant, and so mixed with oily matter, that the capsule becomes 
notably dilated : in others, the pressure of the refluent fluid from the 
obstructed tube compresses the tuft into a small space at the bottom of 
the capsule. Oily matter, in the form of minute dark molecules, and 
various-sized drops, is often present in small, sometimes in considerable 
quantity ; when very abundant, it imparts to the kidney a dead milky 
or yellowish-white aspect. In such cases, the epithelial particles often 
become so filled with oily molecules as to resemble very closely granule- 
cells. In many cases, however, there is no trace of it, and it is certain that 
it is not of the essence of the disease. In the more advanced instances 
of degeneration — before, however, atrophy of the kidney has become 
decidedly apparent, the cortical tubuli exhibit unequivocal traces of 
breaking up. Their basement-membrane is lost ; their epithelium, 
though still preserving the tubular form, is tending to become a mere 
detritus, and the commencing appearance of granulations shows that 
atrophy is taking place in some parts, while others remain prominent 
and distended by their included cell-growth. Microscopic cysts are 
sometimes imbedded in the cortical tissue, and may tend, in some mea- 
sure, to increase the size of the kidney ; but they are not so numerous 
as in the more atrophied condition. The medullary tubuli are less 
affected than the cortical ; those near the base of the cones, especially, 
often are filled by accumulated epithelium, while those nearer the mam- 



552 DEGENERATIVE DISEASE OF THE KIDNEY. 

mellre are more free, and contain either some oily matter, or fibrinous 
casts, or yellow corpuscles, the result of hemorrhagic effusion. The 
matrix-tissue is little altered in itself, but is often infiltrated with a 
granulous exudation-matter, containing a few nuclear corpuscles; these 
are sometimes elongated and developing fibres. The urine produced by 
kidneys in the foregoing condition is generally paler than natural, of 
somewhat altered smell, and deposits a whitish sediment, consisting of 
fibrinous casts, renal epithelium, and vesical scaly particles. Its acidity 
is less than that of the natural secretion, and its specific gravity, which, 
in the earlier stages, may be above, tends to fall more and more below 
the standard of health. While the fibrinous casts contain epithelial par- 
ticles, it may be inferred that their cell-growth is still produced in the 
interior of the tubes; but when the urine deposits large cylindrical casts, 
with very little trace of epithelium imbedded in them, it betokens that 
the basement-membrane is denuded, and that the condition is becoming 
more unfavorable. When oil-drops appear in the epithelium or in the 
casts, it is, of course, a sign that oil is deposited in the kidney ; but it 
is by no means certain that this particular change is of any moment. 
Blood-globules are not generally present, unless as the result of some 
recent congestion. Albumen is constantly present, except in a few rare 
cases, where it disappears for a short time ; its quantity varies con- 
siderably, being, apparently, much more influenced by other circum- 
stances than by the period of the disease. Frerichs states that the daily 
drain from the blood varies from 54 to 360 grains. The quantity of all 
the solids of the urine diminishes as the degeneration advances, the urea, 
the lithates, the alkaline, and earthy salts are all diminished; in one 
case, mentioned bj Dr. Christison, the total amount of solids excreted 
from the kidneys, in twenty-four hours, amounted only to jath of the 
normal average. Dr. Rees has lately shown that an increased quantity 
of extractive matter is often poured out in cases of renal degeneration, 
which constitutes a further drain, in addition to that of the albumen. 

The next condition of kidney which we shall describe is often re- 
garded as a further stage of the preceding; this is, we believe, some- 
times the case, but not by any means necessarily or universally. The 
organ is greatly atrophied, and evidently contracted; its surface is 
covered with irregular prominences, the so-called granulations. Its 
consistence is considerably increased, so that the structure has, as 
Frerichs says, a kind of leathery toughness ; this is more marked in 
proportion to the atrophy. The color is decidedly less pale than in the 
former variety ; it often seems to depend very much on a moderate 
amount of passive hyperaemia. The capsule is always very adherent, 
but it is worth noticing that, sometimes, when it is thickened, a layer of 
it may be peeled off, leaving behind an apparently smooth surface. The 
cortical part is most affected by the atrophy, being reduced, in extreme 
cases, to a layer two or three lines in thickness ; the medullary cones 
suffer in a less degree. The external form is often remarkably tabu- 
lated, reminding one of that of the foetal kidney. Microscopically ex- 
amined, the renal tissue is found to have perished extensively, and this 
generally in proportion to the shrinking of their size. In extreme 
cases, one may scarce find in a section anything except mere granular 



DEGENERATIVE DISEASE OF THE KIDNEY. 



553 



debris; some of these, perhaps, still preserving the contour of the ori- 
ginal tube, but the greater part constituting an indefinite shapeless 

Fig. 251. 




Drawing of atrophied kidney. 

mass. In other less advanced cases, and in some parts, indeed, of all, 
the tubes are still discernible: they are irregularly distended, and 
opaque with granular contents, which have wellnigh, or perhaps com- 



Fig. 252. 




Cortical part of a very granular kidney, containing very numerous microscopic cysts. The tubes are very 
much degenerated and broken up. Two Malpighian bodies are shown. 

pletely blocked up their canals. Oily molecules, sometimes accumulated 
in considerable quantity, lie here and there amid the granular matter, 
and increase the opacity greatly. The granulations are made up of the 
infarcted convolutions of tubes, and are the parts in which most traces 
of the natural structure still persist ; they remain prominent, because 
the intervening parts have perished and shrunk in. The basement- 
membrane of the tubes, in most instances, is lost; occasionally a trace 
of it may be seen, giving a sharp definition to a mass of epithelium; 
but, as a rule, it seems to disappear with advancing degeneration, and 
we cannot confirm the observation of Frerichs and others, that it is still 
existent among the atrophied tissue. 



554 



DEGENERATIVE DISEASE OF THE KIDNEY. 



In specimens where its presence is very manifest in infarcted but not 
atrophied tubes, we have observed sometimes a single tube with its ho- 
mogeneous membrane denuded by separation of the epithelium, as 

Fig. 253. 




The upper figure is from the medullary, the lower from the cortical portion ; they are intended to represent 
a thickened condition of the matrix. Drawn from actual observation by Dr. Sieveking. 

noticed by Dr. Johnson. We have also seen what we think has not yet 
been described, a kind of thickening, or hypertrophy of this membrane, 
which has seemed to us to result from the atrophy of the epithelium, 
and its fusion into an homogeneous layer on the inner surface of the 
tube. The Malpighian tufts, in consequence of the general collapse, 
appear closer together ; a few of them remain tolerably healthy, others 
are compressed and shrunken; often the capsule is filled, to a greater 
or less extent, with an oily-looking matter, or the capillaries are ob- 
scured by fibrinous exudation. When that peculiar condition of the 
blood exists, not very uncommon, which leads to the deposit of "bacony 
matter" in the liver and in the spleen, this is often observed also in 
the interior of the Malpighian capillaries, and we have not detected it 
in any other part of the organ. The membrane of the capillaries has 
rather appeared to us thinned than thickened, as Dr. Johnson describes 
it, and to this thinned and probably otherwise altered condition of their 
tunic, we should ascribe the constant draining of serum that takes 
place. A very important and significant alteration has been observed 
in the condition of the small arteries by Dr. Johnson ; he finds their 
coats considerably thickened, both the inner of longitudinal and the 
outer of circular fibres, and he regards this thickening as an instance 
of true hypertrophy induced by the increased pressure exerted upon 
their parietes by the retardance of the circulation through the inter- 
tubular venous plexus. No particular change is observable in the last- 
mentioned capillaries, or in the veins, except that the latter often con- 
tain firm coagula of blood, which are more or less closely adherent to 
their walls. 



DEGENERATIVE DISEASE OF THE KIDNEY. 



555 



We proceed to the consideration of the cystic growth which often 
takes place so abundantly in diseased kidneys. These formations ap- 
pear as vesicles of very various size, varying from microscopic objects 
of joVo i ncn diameter to the magnitude of a cocoa-nut. They contain 
usually a clear, colorless fluid, which is slightly albuminous, and holds 

Fig. 254. 





T\ 






-< 



Renal cysts, and cyst-like casts, 
(a) Cysts containing cells. 

(6) (b) (b) (b) (fe) (b) Cysts containing granulous matter and nuclei ; in b', thecelloid contents are disposed so 
as to form an epithelium round a central space ; in b", the nuclei are elongated, 
(c, c) Cysts containing granulous and oily matter. 
(d, d, d) Small transparent vesicles. 

(e) Young cyst diameter, l-2000th of an inch in the remains of a tube. 
(/) A cyst with laminated walls. 

(a) Two doubtful cysts, probably casts, without distinct envelop, consisting of granulous and a little oily 
matter. 

(b) An oval fibrinous cast advanced in fatty degeneration. 

(c) Pale, homogeneous, fibrinous casts. 

in solution the ordinary salts of the serum. Sometimes it is of a dark- 
yellowish color, and more or less viscid, indicating, perhaps, the pre- 
sence of colloid matter. We found, in one instance, a large quantity 
of yellowish-granular corpuscles diffused through the fluid, and frag- 
ments of an epithelial pavement, consisting of closely opposed nuclei. 
No urinary principles are found in them, at least as a general rule, but 
oily matter is not unfrequent, and cholesterin is occasionally present. 



556 DEGENERATIVE DISEASE OF THE KIDNEY. 

As they extend and attain a largish size, they seem to cause absorption 
of the cortical rather than of the medullary substance, so that on laying 
open a cyst, a medullary cone may be seen at the bottom of it, and 
forming perhaps a ridge in its interior. Respecting the origin of cysts, 
opinions are divided; Drs. Johnson and Frerichs maintain that they 
are produced by obstruction of the tubes, and subsequent dilatation 
from secretion taking place within them. Mr. Simon first proposed the 
idea that they originate as new formations or growths within the tubes, 
each cyst having its origin in a germ or nucleus particle, such as under 
healthy conditions might have produced an epithelial cell. Rokitansky 
and Paget have also adopted this view, and we have ourselves been long 
convinced of its accuracy. It applies especially to those cases where 
the cyst-formation is extremely abundant, but we are more inclined to 
believe that the few and rather large cysts which occur in kidneys not 
seriously diseased, are produced in the former manner. When the tuft 
in the interior of a Malpighian capsule is compressed and spoiled, we 
believe that a cyst may be developed from the capsule in the same way 
as from a portion of a tube. The smaller cysts contain usually either 
a clear fluid, or granulous, or an admixture of granulous and oily mat- 
ter. The larger ones sometimes contain an endogenous cell-growth. 
The envelop in all is well marked, formed of a distinct homogeneous 
membrane ; it occasionally presents concentric laminae. Oval and round- 
ish fibrinous casts, when impacted in the medullary tubes, may simulate 
very nearly the aspect of cysts, especially when some epithelium is im- 
bedded in them. The more or less altered remains of hemorrhagic effu- 
sions, in the form of black or yellow matter, are not unfrequently met 
with in the cortical substance; in some very rare cases small collections 
of pus have been found, though it is possible these may have proceeded 
only from disintegrating fibrin ; urinary deposits, such as uric acid, urate 
of soda, and oxalate of lime, have sometimes been observed in the tubes; 
and lastly, tuberculosis of the kidney has been noticed, when their organs 
were at the same time affected with Bright's disease. There is nothing 
very characteristic of the urine passed from small atrophied kidneys ; 
it is generally, however, more abundant, of lower specific gravity, of 
paler color, less albuminous, and deposits a less quantity of epithelial 
sediment than that from the enlarged organ. Fibrinous casts will 
rarely be entirely absent, though their quantity, and the presence or 
absence of blood-globules, will depend very much on the degree of con- 
gestion which may be induced by various circumstances. With regard 
to the causes of renal degeneration, it appears that taking first the pre- 
disposing, no age is exempt, but that, as French's Table shows, the 
greater number of cases occur between twenty and forty. If, however, 
we exclude the acute hypersemic attack, as we are inclined to do, the 
number occurring in the early years of life will be much reduced. The 
large mottled kidney is often observed in early adolescence, the con- 
tracted belongs more to a later period. The male sex seems to be more 
affected than the female, but we doubt if this would apply to the true 
degenerations. Whether the scrofulous diathesis occasions special 
liability to the disease is not quite ascertained; we are inclined to think 



DEGENERATIVE DISEASE OF THE KIDNEY. 557 

that it 1 does; a female suffering from very marked renal degeneration 
lately told us, that she had lost three brothers and two sisters " by a 
decay of nature." Occupations attended with much hardship and pri- 
vation are those in which most cases of Bright's disease occurs. A damp 
cold climate is most favorable to the production of renal disease, but it 
is common in tropical regions also. The exciting causes may be referred 
to two classes, the one tending to induce acute hyperemia of the kid- 
neys, and to give rise to that form of Morbus Brightii, which is not 
essentially degenerative; the other by impoverishing the blood, and de- 
pressing the general powers, acting as direct promoters of renal degene- 
ration. In the first class we comprise stimulating diuretics, blows on 
the loins, arrests of perspiration, the congestive influence of the exan- 
themata, and of cholera. In the second, excess in spirituous liquors, 
bad nutrition, inveterate syphilis, mercurial cachexia, and exhausting 
suppurations, as well as the deteriorating effect of continued fever on 
the general system. We do not think that obstructive diseases of the 
heart have much to do with the production of renal degeneration, at the 
most they only act as predisponents. The same may be said of preg- 
nancy; as, though it is, unquestionably, in some instances, the efficient 
cause of renal congestion, and consequent convulsions from uraemia, yet 
Frerichs acknowledges that even among such cases traces of real dege- 
neration are rarely discoverable. We regard, therefore, albuminuria in 
pregnancy and in obstructive heart disease only as an indication that 
the kidney is the seat of a passive hyperemia, which we do not think is 
often followed by actual degeneration. It is possible that the increase 
of fibrin in the blood, which takes place in the latter months of preg- 
nancy, may, where a predisposition exists, induce true M. Brightii, but 
this at least is rare. The effects of renal degeneration manifest them- 
selves primarily and principally in the blood, and as we have already 
spoken of ursemia as a disease of the blood, we shall merely enumerate 
here the changes which it undergoes. The blood-globules are destroyed 
to a very great extent, especially in the advanced stages of the disease, 
the specific gravity and albumen of the serum are diminished, the fibrin 
remains at the normal figure, the extractive matters are slightly increased, 
the quantity of oil and of salts is scarcely altered; urea has often been 
detected in considerable quantity, and becomes most abundant when the 
secretion of urine is very scanty. As this unhealthy blood circulates 
through the system, it occasions disorder and disease of different organs. 
The serous membranes are often inflamed, and pour out copious effusions ; 
the lungs are apt to become congested and infiltrated with fluid, or bron- 
chial catarrh is set up, and becomes habitual ; the brain and medulla 
suffer, and coma, or convulsions, prove fatal ; .dyspepsia, vomiting, and 
diarrhoea may announce disorder of the stomach and intestines; chronic 
rheumatism is a frequent complication ; atheromatous disease of the 
great bloodvessels, and dilatation of the heart, are also with justice 
attributable in some cases to the poisoned state of the nutrient fluid. 
The liver is often found affected with more or less of cirrhotic change, 



1 The first form of degeneration in which the kidney is enlarged and pale, or fatty, 
often met with in patients dying with tubercles and cavities in their lungs. 



is 



558 DEGENERATIVE DISEASE OF THE KIDNEY. 

but we believe this to be rather a coincident effect of the state of the 
blood which produces renal degeneration, than a secondary result of 
that degeneration. 

We come now to the consideration of the nature of Bright's disease, 
excluding the acute hypersemic attack as of a different kind. Frerichs 
makes it entirely consist in a preceding hyperemia, occasioning exuda- 
tion of fibrin into the tubes; this filling of the tubes accounts for the 
increase of size, and the pallor of the kidney ; and the detachment of 
the epithelium he believes is only occasioned by the fibrinous casts adhe- 
ring to it, and carrying it along with themselves when they are swept 
out by the current from the Malpighian tufts. As the coagula and the 
epithelium are carried forth, the tubes collapse, and the kidney thus 
passes into a state of atrophy. The causes of the effusion are, accord- 
ing to Frerichs, either mechanical hinderances to the flow of blood in 
the renal veins, or a supposed paralytic dilatation of the capillaries, 
which may be directly brought about by irritants, or an unnatural 
state of the blood, as in scarlatina, or by a reflex action from the skin. 
We remark upon this theory that it is far too mechanical ; that it takes 
no account of the great number of recoveries which take place after 
acute hypersemic attacks, and does not accord with the frequently latent 
origin of hopeless degenerations ; that it does not explain sufficiently the 
important changes which take place in the epithelium, and in the base- 
ment-membrane, nor why there should be so marked a difference between 
simple Nephritis and M. Brightii. Dr. Johnson's theory, we think, is 
far more tenable; it is expressed by him as follows: "All changes of 
structure commence in the secreting cells of the gland, and are the re- 
sult of an effort made by the cells to eliminate from the blood some ab- 
normal products, some materials which do not naturally enter into the 
composition of the renal secretion." With the first part of this state- 
ment we quite agree, the second we think, is much more doubtful. That 
a diseased state of the blood is the essential cause of renal degeneration, 
we have little doubt, but we conceive that this consists in an unnatural 
state of some of the normal constituents of the blood, probably the 
fibrin or albumen, and that this induces an unhealthy nutrition of the 
renal tissues. As we are ignorant of the way in which the epithelium 
subserves the secretory process, how it eliminates the urea, uric acid, &c, 
from the blood in which they are formed, we cannot understand in what 
way a diseased state of the epithelium disables it from fulfiling its func- 
tion. Comparing, however, generally, the healthy with the morbid 
structure, it may be said that the former conveys the idea of a delicate, 
quickly forming, and quickly changing material, similar to the gray mat- 
ter of the hemispheres, while the latter appearing coarser, more granular, 
and having often more shaped and more consistent particles, seem cer- 
tainly much less apt to undergo rapid change. The hypertrophy of the 
epithelial particles, and their accumulation in the cavity of the tubes, 
may be only the result of their not disintegrating in the formation of 
the secretion as they normally should. Some time ago we examined an 
enlarged thyroid, in which most of the vesicles were filled and distended 
by collected secretion, but some were filled with epithelium only. In 
the same way, sebaceous follicles distended into cysts sometimes contain 



DEGENERATIVE DISEASE OF THE KIDNEY. 559 

considerable quantities of epithelium, sometimes oily matter prepon- 
derates. The accumulation, therefore, of epithelium within the tube, 
is no sign that the cells are striving more actively to eliminate morbid 
matters, but only that, being unhealthily nourished, they do not disinte- 
grate in the secreting act as they normally should. The deposition of 
oil in the cells seems to us also an indication that their vitality is at a 
low ebb, that the plasma out of which they are formed does not main- 
tain its normal composition. So also, the perishing of the basement- 
membrane seems strongly to indicate unhealthy nutrition. The expla- 
nation given by Dr. Johnson, of the mode in which hyperemia of the 
kidney and consequent exudation is produced, seems to us most conso- 
nant with sound pathology. He starts from the important experiment 
of Dr. Reid, which shows so well the effect of arrested nutrition in ob- 
structing the passage of blood through the capillaries of a part. When 
the air-cells of the lung contain a normal proportion of oxygen, the 
blood traverses freely the pulmonic capillaries; when they become sur- 
charged with carbonic acid, the current of the blood is obstructed in the 
same capillaries. The increase of pressure in a hsema-dynamometer in 
an artery, and the decrease in a corresponding vein, show that the un- 
aerated blood cannot traverse freely the systemic capillaries. As the 
cells lose their power of eliminating the urinary constituents, the blood 
passing through the tubular venous plexus is retarded in its course, and a 
continually increasing congestion is set up. This affects necessarily the 
Malpighian tufts, and occasions the draining off of liquor sanguinis from 
them, and often hemorrhage also. The thickening of the walls of the 
small arteries before mentioned is another result of this backward pres- 
sure. We think the term " chronic desquamative nephritis" unsuitable, 
as the hyperemia which it induces is only of a passive kind, resulting 
from obstruction, and herein probably essentially differing from the 
active condition of the acute hyperremic attack. Deposition of oil in 
the degenerating epithelium we hold to be accidental, and not in any 
way essentially modifying the morbid state. As it is most common and 
abundant in the renal cells of dogs and cats, in England and Germany, 
without any disease, so its presence in the condition we are considering 
cannot be of much moment. With regard to the two forms of diseased 
kidney which we have described, we feel some degree of doubt as to the 
exact relationship they bear to each other ; some regard the atrophied 
kidney as the more advanced condition of the enlarged one, others con- 
sider the two as distinct varieties. We strongly incline to the latter 
opinion, and to the belief that the enlarged degenerated kidney possesses 
pathological affinities with phthisis and the class of scrofulous maladies, 
while the contracted eminently granular kidney is allied to such changes 
as those seen in cirrhosis of the liver, and contraction and thickening 
of the cardiac valves. Between the two forms, of which we have tried 
to give a typical description, of course there are very numerous inter- 
mediate ones which the student must expect to find. In some of them, 
it is scarcely possible to determine by the naked eye whether the organ 
be diseased or not ; but a careful microscopic examination of the cortical 
tubes, the Malpighian bodies, and the medullary tubes, together with a 
reference to the state of the urine during life, will usually clear up all 



560 DEGENERATIVE DISEASE OF THE KIDNEY. 

doubt. The adhesion of the capsule to the surface, if decidedly un- 
natural, is a valuable morbid sign. 

Tubercular disease of the kidney. — Tubercle is not of frequent occur- 
rence in the kidneys. These organs stand only in the eighth place of 
the scale given by Rokitansky. It is found sometimes in the miliary 
form, sometimes in larger masses, which preserve the shape of the part 
in which their substance seems to be infiltrated ; sometimes it extends 
to the kidneys, from the mucous membrane of the calices, and proceed- 
ing up along the sides of the cones, gradually advances inwards into the 
secreting structure. The miliary granulation is sometimes (when a high 
degree of tubercular dyscrasia exists) associated with a considerable 
amount of hyperemia of the organ ; when the deposit takes place in a 
chronic manner, the surrounding tissue is quite pale. The large masses 
that extend throughout the diameter of the kidney, from the surface to 
the hilus, are remarkably bloodless. This is well shown in some injected 
specimens in the museum of St. George's Hospital. When the tuber- 
cular deposit extends to the renal tissue, from the mucous membrane of 
the calices and pelvis, these cavities become remarkably enlarged ; they 
extend up on the sides of the cones, into the cortical substance, and 
approach more or less near to the surface. At the same time, the whole 
organ is enlarged, and appears rather pale. The epithelial lining of 
the tubes is more or less opaque and granular, or of oily aspect. As in 
other situations, the tuberculous matter tends to soften and break down, 
and thus cavities are formed sometimes of rather large size. These may 
contain a mixture of tuberculous detritus and pus. Fibrinous moulds 
in great numbers are sometimes present in the tubes. The middle period 
of life is that at which the disease is most liable to occur. In most cases 
there is a deposit of tubercle in other organs, especially in the lungs, 
and often in various parts of the genito-urinary apparatus. 

Cancer. — We have not exact data for determining the frequency of 
renal cancer, but it is certainly not rare. Secondary seems to be more 
frequent than primary cancer. Scirrhus is rarely if ever found ; and 
the same may be said of colloid. Encephaloid growths, especially, we 
think, in children, attain in the kidney an enormous size. A case has 
been mentioned to us by Dr. T. K. Chambers, in which the weight of 
the tumor was three-fourths that of the whole body. No trace of the 
kidney was discoverable in this case, on the side of the tumor, and the 
ureter was lost in it above. The liver contained some smaller tumors 
of similar kind. These facts seem sufficiently to prove the renal origin 
of the tumor. In a specimen in the museum of St. George's Hospital, 
there are several small cystic cavities in a carcinomatous renal growth. 
The statement of M. Rayer, that cancer of the liver and right kidney 
frequently coexist, as well as cancer of the adjacent parts of the stomach, 
or descending colon and left kidney, is confirmed by Dr. Walshe. Roki- 
tansky notices that cancer of the kidney often coexists with cancer of 
the testis on the same side; the renal disease, we think, is most commonly 
ieveloped after that of the testis. "In thirty-five cases of renal cancer, 
the disease," Dr. Walshe says, "affected both organs sixteen times, the 
right alone thirteen times, the left alone six." The table given by this 
author, shows that the period from fifty to seventy is that which is far 



ANOMALOUS CONDITIONS OF THE URINARY PASSAGES. 561 

most liable to cancer of the kidney. Ten cases only occurred in the 
previous years of life, while nineteen were noted in the succeeding twenty. 

The urine excreted by cancerous kidneys, may long retain its natural 
characters. In a case recorded in the Transactions of the Pathological 
Society, 1846-47, nothing remarkable seems to have been observed in 
it, although both kidneys were converted entirely into encephaloid masses. 
When, however, the growth softens and breaks down, blood, puriform 
matter, or cancerous detritus, may appear in the urine. 

Entozoa occurring in the kidney, are the acephalocyst, the cysticercus, 
and the strongylus gigas. The so-called hydatids from the first of these 
have, in rare cases, been passed with the urine. 

The adipose tissue, in which the kidney lies imbedded, may increase 
to such a degree as to penetrate by the hilus into the substance of the 
organ, impede its nutrition, and induce a kind of atrophy. Rokitansky 
states that, in the highest degree of this change, the kidney presents the 
appearance of a mere mass of fat, without the slightest traces of renal 
organization ; the urinary passages at the same time being atrophied and 
obliterated. 

The capsule of the kidney may be inflamed, in consequence of which 
fibroid thickening may take place, and more or less of induration, atro- 
phy, and obliteration of the organ. The cortical substance is especially 
apt to be involved, and the surface is sometimes overspread with purulent 
matter, while the tissue itself becomes sloughy or gangrenous, or is only 
congested and softened. 



ANOMALOUS CONDITIONS OF THE URINARY PASSAGES. 

Under these we comprise the ureters, and their upper termination, as 
the pelvis and calices of the kidney. The ureters may terminate from 
congenital defect, in a cul-de-sac, either in the vicinity of the kidney or 
of the bladder. Sometimes they are double or triple, usually from fissure 
of the pelvis of the kidneys, but they generally unite again before their 
vesical termination. It is not uncommon to find them considerably 
dilated, when the opening into the bladder has been greatly narrowed 
or obliterated. The calices expand at the expense of the renal tissue, 
and extend outwards towards the surface, till at length there remains 
only a thin layer of the cortical substance compressed against the in- 
vesting capsule, and the kidney is converted into a number of pouches, 
separated by membranous loculi, which contain the remains of the me- 
dullary cones. The surface of the kidney becomes lobulated in a marked 
manner from the pouches, pressing outward between the interlobular 
septa. The ureters are at the same time distended, sometimes to that 
extent that they resemble a portion of small intestine; at the same time, 
their walls are somewhat thickened, so that they do not appear to be 
much thinner than natural; they only attain, however, a considerable 
thickness when there is concurrent inflammation. The ureters become 
also increased in length, and therefore do not lie straight, but are thrown 
into coils or flexures. Their mucous lining does not appear to be so 
often inflamed or ulcerated as that of the calices and pelvis. The 
36 



562 ANOMALOUS CONDITIONS OF THE URINARY PASSAGES. 



pouches formed by the dilatations of these, are often filled with puriform 
fluid, or with a mixture of pus and urine, or even with clear serum only. 
To the latter condition, the term hydrops renalis has been given. It 
seems to take place when the obstruction to the flow of urine into the 
bladder is complete, and when, in consequence, after extreme distension 

Fig. 255. 




Kidney converted into cysts. 
Fig. 256. 




Pyelitis ; there was a concretion in the ureter, conpisting of phosphates and animal matter. 

and atrophy of the renal tissue, the secretion of true urine ceases, and 
is replaced by a mere serous fluid. After a time, such tumors may di- 
minish, and almost disappear, from the absorption of their contents. 
The ureters in such cases also contract, and become obliterated. It 
frequently happens that the renal tissue not .only atrophies, but also 
becomes inflamed, and infiltrated with pus, so that it is still further in- 
capacitated from carrying on its function, and death ensues from the 
effects of urea being retained in the blood. 

Inflammation of the urinary passages often coexist with the state of 
dilatation ; it may also occur, though much more rarely, as a primary 
disease. It is not unfrequently produced by the irritation of calculi, or 



ANOMALOUS CONDITIONS OF THE URINARY PASSAGES. 563 

results from the extension of vesical disease, or from metastasis of this, 
according to Rokitansky. Stricture of the urethra is a common cause 
of disease of the mucous membrane of the bladder, as well as of dilata- 
tion of the ureters. The inflammation set up there is very prone to 
creep backward, and affect the urinary passages, which are predisposed 
to it by their unnatural distension, and the prolonged contact of un- 
healthy urine. The mucous membrane is found in various degrees tume- 
fied, injected, or of a saturated red color, of villous aspect, and covered 
with a muco-purulent fluid. Perforation of the ureters may take place 
in consequence of sloughing, the urine infiltrating into the adjacent tis- 
sues, and producing either extensive sloughing, or circumscribed ab- 
scesses. The inflamed mucous membrane, in many cases, either secretes 
phosphates, or a mixture of these and carbonates ; or these may be 
deposited from the urine. When atrophy of the kidney takes place, 
these saline deposits, cemented together by mucus, form a " yellowish- 
white, greasy, and chalky pulp, which fills the calices," and is inclosed 
by the wasted organ as by a cyst. In other cases, a renal calculus, 
such as is described by Dr. Prout as the Phosphatic, may be produced 
in this way, and become itself a further cause of irritation and disor- 
ganization to the kidney. 

Rokitansky mentions the occurrence of inflammation, which he dis- 
tinguishes by the name Exudative, from the above catarrhal form, as a 
secondary affection in cases of serious blood disease. It is observed in 
typhus, in the exanthemata, in diphtheritis, and acute tuberculosis, and 
also in pyaemia, and occasions the formation of unhealthy fibrinous 
effusions upon the mucous surface, associated in cases of necraemia with 
hemorrhage. 

Cysts, containing a glutinous or hard (colloid ?) matter, about the size 
of millet-seeds or peas, are occasionally found developed under the mu- 
cous membrane of the urinary passages. 

Tubercle. — Rokitansky states that this " is always a symptom of 
tubercular disease, that has spread from the male genitals to the urinary 
organs." We think some cases recorded in the Transactions of the 
Pathological Society, and some that we have seen ourselves, show that 
this is by no means necessarily the case. It is most frequent in the 
ureters when the kidneys are involved at the same time, but we have 
seen it in them when the kidneys were healthy. Usually, there exists 
at the same time tuberculosis of some important organ, as of the lungs 
or the hip-joint. The deposit takes place in the submucous tissue, and 
forms, when its progress is chronic, gray granulations, which become 
yellow, soften, " and give rise to small circular ulcers." When the 
disease is more acute, larger patches of deposit are formed, or " the 
mucous membrane becomes infiltrated throughout with the tubercular 
product of inflammation, which is at once detached as a cheesy, puru- 
lent mass." 

Cancer but rarely attacks the urinary passages, and only when it is 
elsewhere in process of development. The disease may extend to them 
from the kidney, from the lumbar glands, or from the bladder, either 
when it is itself primarily affected, or involved in uterine cancer. 



56i 



ANOMALOUS CONDITIONS OF THE BLADDER. 



ANOMALOUS CONDITIONS OF THE BLADDER. 

This receptacle is subject to various congenital malformations, of 
■which we shall only mention two. The first is termed inversion of the 
bladder, and results from a defect in the lowe? part of the abdominal 
parietes. There appears in the hjpogastrium " a red, mucous, dilated 

Fig. 257. 




Extrophy of the bladder, a. Everted bladder. 6, b. Orifices of the ureters, c. Penis without urethra. 
d, d. Pubic symphysis, e. Scrotum and testis. /. Congenital inguinal hernia. — From Gross on the Urinary 
Organs. 

spot, the edges of w r hich join with the common integument ; in the male 
sex it passes downwards, so as to terminate in the fissure of the urethra; 
in the female it is surrounded by two diverging tumors, which represent 
the labia, and it terminates in the lamina of the general integument 
which invests the rima vulvae." The opening of the ureters are seen at 
the lower and lateral parts of this mucous surface, which is, of course, 
the posterior wall of the bladder. In a case which we saw recently, 
the penis was very short, and the canal of the urethra open above in its 
whole length. The second malformation is attended with fissure of the 
opposite side of the bladder, and of the adjacent cavities, so that a kind 
of cloaca is formed, similar to that which exists in the lower animals. In 
some rare cases the urachus remains pervious, so that when urine is 
passed it escapes at the umbilicus. In others, again, the bladder has 
no external opening, the communication with the urethra is not formed. 
Dilatation of the bladder is no uncommon occurrence, and may be 
occasioned either by paralysis of the muscular tunic, or by some obstacle 
to the outflow of the urine, as stricture of the urethra. We think that 
the amount of dilatation is greatest when the muscular coat is paralyzed, 



ANOMALOUS CONDITIONS OF THE BLADDER. 565 

and that in the other class of cases, where some obstruction exists, the 
great hypertrophy of the muscular fibres which is induced prevents the 
distension becoming so great. Rokitansky, however, seems to consider 
obstruction as the most powerful cause of dilatation of the bladder. The 
effect of the stronger contractile coat of the bladder in preventing dila- 
tation, is shown in some cases recorded in the Transactions of the Pa- 
thological Society, in which it is mentioned that the ureters were much 
distended, while the bladder was contracted, or not dilated. The blad- 
der may be so dilated as to rise above the umbilicus considerably, and 
to contain twenty pints of urine. The paralytic dilatation depends, we 
believe, in some cases, on fatty degeneration of the muscular coat. 
Diverticula, or partial dilatations of the bladder, are not infrequent. 
They are always found in cases in which the muscular tunic is hyper- 
trophied, and seem to be produced by protrusions of the mucous mem- 
brane taking place between the fasciculi, which are subsequently pushed 
outwards more and more by the pressure of the urine. The lateral 

Fig. 258. 




Sacculation or partial dilatations of the bladder; section of the bladder and prostate, a. Mucous surface of 
the bladder. &, 6. Lateral lobes of the prostate, c. Middle lobe. d. Large cyst or pouch, partially laid open, 
and communicating with the bladder by a small orifice. — From Gross on the Urinary Organs. 

portions, the posterior surface, or the neighborhood of the fundus, are 
the situations in which diverticuli usually form. They have no muscular 
tunic, except, occasionally, a few scattered fibres, which Rokitansky 
suggests may be some evidence of their being congenital. Calculi get 
into these pouches sometimes, and become so lodged and concealed as to 
escape detection by the sound. 

Contraction of the bladder most often is rather apparent than real, 
and depends on irritation of the mucous lining, with hypertrophy of 
the muscular coat. Sometimes it is partial, or may cause a kind of 
hour-glass constriction of the cavity. When a calculus is present, the 



566 



ANOMALOUS CONDITIONS OF THE BLADDER. 



walls are sometimes found closely embracing it; and a case is mentioned 
by Morgagni, in which the bladder was so closely contracted around a 
needle, that there was scarce room for anything more in its cavity. 

Hypertrophy of the muscular coat is observed in cases where that 
tissue is unusually exercised, and is often of a manifestly beneficial tend- 
ency. When the mucous lining is irritated by the contact of unhealthy 
urine, perhaps in some degree inflamed or ulcerated, the reflected stimu- 
lus from the spinal cord becomes more intense, and the contractions of 
the muscular fibres more energetic. Again, when in consequence of 
stricture, the difficulty of expelling the urine becomes great, the con- 
tractile force is increased to meet it, and this increase is occasioned by 
the greater exertions which are necessary. The appearance of the inner 
surface of a bladder whose muscular coat is hypertrophied, is peculiar, 
and is well compared by Rokitansky to that of the right ventricle of the 
heart. The muscular fasciculi become unusually prominent, and by their 
divisions and interlacements produce a kind of irregular network into 

Fig. 259. 




Hypertrophy of the muscular coat of the bladder.— From Gross on the Urinary Organs. 

the meshes of which the mucous membrane dips, and through which it 
may be forced in sacculi. The technical term for this condition is colum- 
nated, or in the French original, vessie a colonnes. Dr. Walshe has 
seen polypoid growths from the inner surface of the bladder, consisting 
of prolongations of the mucous and submucous tissue, in a state of simple 
hypertrophy. If we except these, and the diverticula before mentioned, 
it does not appear that there is any true hypertrophy of the mucous 
lining. Rokitansky has, in rare cases, seen the mucous membrane 
atrophied, " reduced to a very delicate, shining membrane, resembling 
the arachnoid," while the muscular coat almost entirely disappears. 

The bladder is liable to various displacements. It may form the con- 
tents of inguinal, vaginal, and perineal hernia, it may be introverted 
and forced into the urethra, and even in females project from the meatus 



ANOMALOUS CONDITIONS OF THE BLADDER. 567 

urinarius externally. 1 When hernia of the bladder occurs, it is either 
in part, or, more rarely, completely destitute of peritoneal covering. 
This depends on the anterior part of the viscus, which has no serous 
covering, being the first to prolapse ; but, as the organ descends, the 
posterior part which is lined, carries with it the peritoneum, and thus 
forms a sac, into which intestine or omentum is often protruded. 

Hyperemia of the bladder of a passive kind, occurs when there is 
some obstruction to the free passage of blood through the pelvic veins 
and the V. cava ; it is, therefore, associated generally with a similar 
condition of the adjacent viscera. It produces increased secretion of 
mucus, sometimes spots of extravasation, and occasionally such dilata- 
tions of the veins as have been termed vesical haemorrhoids. These, 
however, do not appear like the common little tumors of the rectum, but 
rather as prominent and distended vessels. 

Inflammation of the bladder is much more often seen in a chronic 
than in an acute form; this depends partly on the acute stage of the 
disease in recent cases having generally subsided before death occurs, 
partly on the greater frequency of cystitis, which is chronic from the 
commencement. The appearances in acute cystitis are strong vascular 
injection of the mucous lining, with brownish patches in the vicinity of 
the neck and fundus ; more or less thickening of the membrane, with 
exudation of fibrin or pus on the surface, or foci of the latter in its sub- 
stance. The mucous tissue may be ulcerated at several points, softened, 
or affected by commencing gangrene. Abscesses may form in the sub- 
stance of the parietes, and open either into the cavity of the bladder, 
or upon its external surface. Sometimes the mucous membrane is almost 
completely destroyed, a few shreds or filaments being the only traces 
remaining, while the muscular tunic is left as if cleanly dissected. This 
is probably the result of phagedenic ulceration. 

Chronic cystitis may be the condition resulting from one or more 
attacks of the acute form, or may be produced by the extension of ure- 
thral inflammation, or by the irritation of unhealthy urine, or of calculi. 
Its characters are various degrees of vascular injection, mingled with 
dark-reddish, slaty or bluish-black discoloration, more or less tumefac- 
tion of the mucous membrane, with secretion of mucus, or muco-pus, 
often in considerable quantity. Sometimes, from the irritation excited, 
the muscular coat becomes hypertrophied and columnated; but the more 
ordinary condition in chronic cystitis, is the thickening and more or less 
uniform induration of the parietes, which assume an homogeneous, lar- 
daceous appearance, doubtless from their infiltration with exudation 
matter. It not unfrequently happens that an acute attack, or exacer- 
bation, supervenes upon a state of chronic inflammation. The following 
abridged account of the appearances which then present themselves, is 
taken from Rokitansky: " The bladder is found dilated, and filled with 
decomposed, intensely alkaline urine, mixed up with blood of a brown 
color, viscid mucus and pus, sanies, lymph, and detached portions of 

1 In the Report of the Path. Soc. 1852-53, there is an instance recorded by Mr. Pilcher, 
in which about two-thirds of the bladder were extruded from the abdomen through the 
inguinal canal, and lodged in the scrotum. The hernial portion was large enough to con- 
tain 50 oz. of fluid. 



568 ANOMALOUS CONDITIONS OF THE BLADDER. 

mucous tissue, in the shape of discolored flocculi, or larger patches.'' 
The mucous membrane, incrusted by a deposit of amorphous and crys- 
talline phosphates, is sometimes " of a dark-red color, appears spongy, 
softened, and pultaceous, is easily detached and bleeds ; when chocolate- 
colored or greenish, it is found purulent, infiltrated with sanious matter, 
or converted into a friable flocculent tissue, which is traversed by the 
urinary sediment." In some cases, the submucous and muscular tunics 
are exposed, and are in various stages of softening, suppuration, and 
disintegration. As the morbid action advances outwards, the peritoneum 
at last becomes involved, and general inflammation of this membrane 
may be set up. Ulceration, attended or not with suppuration, some- 
times extends deeply and gradually, and at last perforates the walls, 
when extravasation of urine takes place, if not prevented by inflamma- 
tory exudation, and adhesion of adjacent parts. The further progress 
of ulceration sometimes forms a communication with the cavities of the 
adherent viscera ; in this way the walls of the rectum, the colon, and 
the ilium, have been perforated, and their contents have made their way 
into the cavity of the bladder. We lately examined a portion of a blad- 
der which had long been the seat of calculous irritation, and had been 
further inflamed by the operation for lithotrity, the man dying of pyaemia. 
The true mucous membrane was in great measure destroyed ; there was 
no trace of basement-membrane or epithelium ; the tissue was thickened 
by indurating exudation and granular matter, and incrusted with amor- 
phous granular particles and prisms of triple phosphate ; or scraping off 
this layer, the surface beneath appeared red and bleeding. No trace 
could be found of the muscular coat, it was replaced by a thick layer of 
fat, consisting of large, well-formed vesicles. Chronic or subacute in- 
flammation of the bladder is very commonly an attendant upon para- 
plegia, and proves the immediate cause of death. The inflammation is 
set up, we conceive, in the same way as that of the eye is when the fifth 
pair of nerves has been divided, and results from loss of the nutrient 
power of the tissues, and consequent stagnation of blood in toneless 
vessels. At the same time, the urine rendered alkaline by the decom- 
posing influence of the vesical mucus upon the urea, reacts, no doubt, 
upon the inflamed membrane as a further cause of irritation. The urine 
is turbid with quantities of muco-pus and detached epithelium, contains 
often albumen, sometimes blood, and always prisms of the triple phos- 
phate. The coats of the bladder undergo similar changes to those above 
mentioned, but of a marked asthenic character. The mucous membrane 
is congested, and thickened and altered by fibrinous exudation, or puru- 
lent, or sanious ; it is incrusted by a phosphatic deposit, and in parts 
may be gangrenous. The muscular coat is also more or less affected, 
and the submucous tissue. Rokitansky describes exudative processes of 
a croupy kind, as not very unfrequent in the bladder; they occur in the 
course of exanthematic diseases, in pyaemia and typhus. The exudation 
does not affect generally a large surface, but is limited " to round spots 
or strise." The mucous membrane beneath the exudation is more or 
less injected, tumefied, and indurated, or in processes of lower character 
is softened and converted into a pulpy, gelatinous, sanious, or purulent 
mass, or even becomes gangrenous. Rokitansky has not seen variolous 



ANOMALOUS CONDITIONS OF THE BLADDER. 56Q 

pustules upon the vesical mucous membrane, as others state they have, 
but he mentions, what we have once observed ourselves, an eruption of 
minute miliary vesicles, containing a clear serosity upon the surface ; 
they accompany, he says, catarrhal inflammation and slight exudative 
processes, as well as Asiatic cholera. Acute and chronic inflammation 
of the muscular coat of the bladder are both spoken and written of, but 
the former appears to take place only as a part of general cystitis, and 
the latter, if it intend more than hypertrophy of the muscular fasciculi, 
is only that general infiltration of the parietes, with induration-matter, 
which we have before noticed. 

Pericystitis, however, seems to be a more distinct affection ; it con- 
sists in the spontaneous inflammation of the cellular tissue surrounding 
the bladder, arising either as a primary or a secondary process. It is to 
be regarded, Rokitansky says, as a localization of pyaemia. From its 
original seat, it is apt to spread to the areolar tissue round the rectum, 
to the anus, and into the scrotum ; it may involve also the coats of the 
bladder, and cause perforation of them. It is sometimes of a chronic 
form, and then gives rise to induration, rigidity, and callosity of the 
bladder. 

Softening of the mucous membrane, not resulting from inflammation, 
was observed by M. Louis only twice out of five hundred autopsies ; in 
these, the tissue was converted into a kind of pale mucilage. Rokitansky 
has seen it only once, in a case of typhus. 

Tubercle is infrequent in the bladder, and is sometimes absent when 
the kidneys are extensively affected by its deposit. It is only met with 
in the form of separate granulations, which are surrounded by more or 
less hyperemia, according to the rapidity of their production ; these 
soften and give rise to circular ulcers of the mucous membrane covering 
them. The cervix and fundus are the parts chiefly affected. 

Cancer is much more often seen in the bladder as the extension of 
disease from contiguous parts than as the primary phenomenon. This 
at least seems to be the more general opinion ; but Dr. Walshe affirms 
that primary vesical cancer is far from being so uncommon as is gene- 
rally supposed, and we are quite inclined to agree with him. Scirrhus 
is very rare in the vesical parietes. Mr. Coulson has never seen it, nor 
has Sir B. Brodie, except where it constituted part only of a morbid 
growth. Rokitansky mentions having seen it extending over large sur- 
faces of the sides of the bladder. Encephaloid, forming nodulated 
prominences or cauliflower-like excrescences, is the form which vesical 
cancer commonly assumes. These may be of very various consistence, 
and often very vascular, easily bleeding, and situated especially at the 
trigone, the neck, the fundus, and the vicinity of the urethral orifices. 
They are developed in the submucous tissue ; but, as they grow, the 
mucous membrane is destroyed, and either an ulcer is produced, or a 
soft, luxuriant, fungous mass. They produce irritation of the bladder, 
more or less difficulty in micturition, and, in the latter stages, hemorrhage, 
which may be considerable and difficult to arrest. The urine contains 
mucus, sometimes blood, cancerous detritus, and portions of encephaloid 
matter, at various times, when they happen to become detached. 



570 MORBID CONDITIONS OF THE URETHRA, 



MORBID CONDITIONS OF THE URETHRA. 

We notice the following malformations : fissure on the upper surface 
(epispadia), or on the lower (hypospadia)', the former, when extending 
the whole length, occurs as a complication of eversion of the bladder; 
the latter accompanies fissures of the scrotum, and occasions a resem- 
blance to the female conformation. The urethra may terminate at various 
points of its normal course, in the perineum, the root of the scrotum, or 
anywhere between this and the glans ; the opening in these unnatural 
situations is very small, and sometimes is completely closed (atresia 
urethrse). A kind of cloacal formation may also be produced by the 
urethra terminating in the rectum, or in the female in the vagina. The 
diameter of the canal may be congenitally narrowed at the extremity, or 
at other parts. 

Contraction, however, is much more commonly the result of inflamma- 
tory disease, under which head we shall describe it. 

Dilatation of the urethra is often produced by some obstruction to the 
flow of urine ; it occurs, for the most part, in the membranous portion, 
which is expanded into a pouch, sometimes as large as a small orange. 
The mucous lining of these pouches is usually "injected and thickened, 
presenting fungous vegetations, and occasionally coated with lymph." 
The urethra is frequently distorted from its normal direction, either by 
the dragging of large scrotal herniae or hydroceles, or by the pressure 
of tumors. Enlargement of the lateral lobes of the prostate pushes it 
to one side, of the middle lobe divides it into two passages. The length 
of the canal, in such cases, is increased. 

Lacerations of the urethra may be produced by mechanical injuries, 
by the passage of fragments of calculi, or by ulcerative destruction. 
They often give rise to urinary fistulae. 

Inflammation of the urethra, of the catarrhal kind, is exceedingly 
common, and constitutes the misnamed gonorrhoea. It commences at 
the anterior extremity, and gradually proceeds backwards, in very severe 
cases extending even to the bladder. The mucous lining becomes swollen, 
injected, and covered with mucous or muco-purulent secretion. Its fol- 
licles and lacunae are attacked, especially the lacuna magna ; in the 
chronic state they are enlarged and relaxed, and pour out, as well as the 
general surface, a thin mucous, so-called gleety, discharge. During the 
acute stage, when the inflammation extends deeper to the fibrous structure 
of the corpus spongiosum, exudation of fibrin sometimes takes place in 
the venous cells, which renders them incapable of distension, and thus 
occasions, during erection, a bending of the j>enis towards the affected 
part which is termed chordee. Abscess may form also in the same situ- 
ation, from suppuration of the exuded fibrin, or, perhaps, also from severe 
inflammation of the lacunae. The inflammation may spread along the 
continuous mucous lining to other adjacent parts, to Cowper's gland, the 
prostate, the vesiculse seminales, and the testicles. This extension of 
the morbid action to other parts is commonly attended by a subsidence 
of it in its original seat, so that it is often questionable whether actual 
metastasis has not occurred. The gonorrhceal discharge passes through 



MORBID CONDITIONS OF THE URETHRA. 



571 



the same stages as that from other inflamed mucous surfaces ; it is at first 
a thin mucous fluid, then more tenacious and muco-purulent or purulent, 
and, as the inflammation subsides, it becomes again thin and pale. When 
a chancre coexists with gonorrhoea, "the discharge has usually a grayish 
or reddish tint, or sanious aspect." The mucous follicles in the vicinity 
of the meatus are liable to be specially affected both in the male and 
female. Dr. Oldham appears to refer to this condition under the name 
of follicular inflammation of the vulva; and Kleeberg, as quoted by 
Dr. Adams, thus speaks of their condition in the male: "The orifices of 
the lacunae become closed by inflammation, and in the course of two or 
three days pustules are formed in their places, which break and discharge 
a yellow pus. The orifices of the large mucous follicles are now seen 
dilated and surrounded by a swollen dark-red border, and they discharge 
a muco-purulent fluid into the urethra." The disease sometimes assumes 
a chronic form. The contact of unhealthy vaginal secretion is the most 
common cause of urethritis, and it is important to be aware that this 
effect may be produced by the fluids of females who are perfectly chaste. 
Stimulating injections, the irritation of calculous fragments, the presence 
of stimulating diuretics in the blood, the materies morbi of gout, of 
influenza, and the suppression of cutaneous eruptions, are mentioned as 
causes of this inflammation. Abrasions and excoriations of the urethral 
mucous lining are occasionally found when it is inflamed, but ulcerations 
are (probably) always the effect of other causes. The syphilitic poison 
producing urethral chancre, the presence of foreign bodies, calculi, &c, 
the irritation caused by a stricture in the part behind, softening tubercle, 
are so many causes of more or less extensive ulceration. It is said by 
Mr. Adams to occur in rare cases spontaneously. 

A very frequent result of inflammation is stricture. This consists in 
a narrowing of the canal from some organic change in the structure 



Fig. 260. 



Fig. 261. 




jjjj;: 




Strictured urethra. 



Strictured urethra. 



of the part itself, or in that of those around. It may affect any part, 
but is most frequent in the anterior part of the membranous portion. 
Out of one hundred and eighty-nine cases examined by Mr. Phillips, 



572 



MORBID CONDITIONS OF THE URETHRA, 



the seat of the stricture was in one hundred and thirty-eight from 
four to six and a half inches distant from the meatus. Contusions 
and wouncls occasion stricture of the urethra, which, in severe cases of 
the latter is extremely intractable. The simplest form of stricture is 
when the canal is partially occluded by a fold of membrane passing 
across it ; this may be of such a shape that a crescentic, or, sometimes, 
an annular opening is left. Several of these strictures may coexist in 
the same urethra ; as many as eight are s^iid to have been observed by 



Fig. 262. 



Fig. 263. 





Strictured urethra. 



Strictured urethra. 



Calot. They are probably produced by the organization of fibrin effused 
on the mucous surface ; others believe that they may result from the 
healing of an ulcer, or the raising up of a fold of the lining membrane. 
In the more common kind of stricture the urethra is narrowed in a much 
greater extent of its course, and sometimes in an extreme degree. Half 
an inch or an inch is not uncommonly the length of the contracted 
part, and sometimes the whole extent of the spongy portion is affected. 
The stricture occupies sometimes one side, at others it completely en- 
circles the canal. It is not difficult to understand the mode of its pro- 
duction, which is very illustrative of the general contractile tendency of 
exudation-matter. Fibrin is effused during inflammation in the mucous 
tissue itself, or in the submucous, as well as sometimes in the corpus 
spongiosum ; if this be not absorbed, it passes into the state of fibroid 
or induration-matter, and continually tends to shrink up and contract 
into a narrower space. In proportion as this takes place, the canal 
must be contracted. The mucous membrane lining the indurated part, 
is often ulcerated and destroyed, commonly from the mechanical effect 
of catheters pushed against it ; but it may also take place spontane- 
ously, and it has happened that the indurated part being destroyed by 
the extending ulceration, the stricture has thereby been cured. A more 
common and less favorable result of deep ulcerations is the perforation 
of the canal and the formation of a fistulous opening. When the ob- 
struction occasioned by a stricture is very great, and it may be such 
that the passage will hardly admit a bristle, the urethra behind is dilated, 
often inflamed, and sometimes ulcerated, so as to give rise to urinary 



MORBID CONDITIONS OF THE URETHRA. 573 

fistula, or effusion of urine. The bladder and ureters are affected as we 
have before described. Of course the hypertrophy of the bladder, by 
propelling the urine more forcibly against the stricture, must tend to 
increase the dilatation of the canal behind. The urethra is sometimes 
obstructed by warty growths, which are situated generally near the 
meatus, and are remarkably vascular ; they are developed as the result 
of gonorrhoea, and polypous growth is occasionally found, but is much 
more rare. Chronic diseases of the lacunae sometimes converts them 
into small indurated tumors, which become imbedded in the corpus spon- 
giosum ; of this kind, perhaps, is an instance mentioned by Rokitansky, 
in which numerous cartilaginous protuberances, from the size of a millet 
seed to that of a pea, were scattered over the surface as far back as the 
bulb, not, however, obstructing the passage. It may be well to remind 
the student that the common expression of " old cartilaginous stric- 
tures" intend simply the density and firmness of the induration-matter, 
and not at all that it contains any true cartilage. Stricture is rare 
before puberty, but has been found at the age of ten years ; it is well 
to be aware that it may at this age, possibly, be the result of the habit 
of masturbation. Mr. Adams enters his caveat against the "indiscri- 
minate use of stimulating injections" as an occasional cause of stricture. 
Fibrinous exudation in very rare cases occurs primarily on the urethral 
mucous lining, and chiefly in children. It is probable that it takes 
place also here as a secondary process in the same diseases in which it 
is found in the bladder and ureters. Variolous pustules are not unfre- 
quent in the urethra. Tubercle is of rare occurrence in the urethra ; it 
is only present when the entire urinary apparatus is likewise affected. 
It has been found in the miliary as well as in the more massive form. 
Cancer affects the urethra, either in the male or female, for the most 
part, as an extension of adjacent disease ; but cases are recorded where 
the growth in this part was either primary or isolated. Dr. Walshe is 
inclined to think that the vascular excrescence of the meatus in the 
female may " acquire a basis of scirrhus, or become infiltrated with 
encephaloid." 

We notice separately the morbid conditions of the female urethra. 
Displacements of the uterus, especially retroversion, cause compression 
of the passage, as also does the pressure of the child's head during labor. 
Such compression not unfrequently produces sloughing of the parietes 
and vesico-vaginal fistula. Dilatation of the urethra is in rare cases 
congenital; it is sometimes effected purposely for the sake of removing 
calculi from the bladder, and may be safely carried to the extent of per- 
mitting a stone one inch and a half in diameter to be extracted. Para- 
lysis, however has sometimes resulted, and consequent incontinence of 
urine from excessive dilatation. Prolapsus of the bladder alters the 
direction of the canal of the urethra so that it passes upwards and 
forwards. There is no essential difference between catarrhal inflam- 
mation of the female and of the male urethra ; it is generally consecu- 
tive to a similar condition of the vagina. The lips of the meatus 
are seen to be swollen, and on pressure upwards muco-pus flows from 
the orifice. Stricture is very rarely, indeed, the result of inflammation, 
which appears to be owing chiefly to the circumstance that the disease 



574 MORBID CONDITIONS OF THE URINE. 

in the female is not of long duration. Mr. Curling met with a case in 
which a stricture, attended with complete retention of urine, was pro- 
duced by contusion experienced during a severe labor. The vascular 
tumor of the meatus is thus described by Sir Charles Clarke: "Its text- 
ure is seldom firm; it is of a florid scarlet color, resembling arterial 
blood ; and if violence is offered to it, blood of the same color is effused. 
It is exquisitely tender to the touch; and if an accurate examination of 
it be made, it appears to shoot from the inside of the urethra. Its 
attachment is so slight that it appears like a detached body lying upon 
the parts." Sometimes the growths extend partially along the urethra, 
or may even be situated at the neck of the bladder. The tissues of the 
urethra occasionally undergo a kind of chronic hypertrophy, so as to 
form "a bulbous tumor." The veins are enlarged and varicose, and the 
areolar tissue increased in quantity, while the mucous membrane may 
be either thick, or, on the contrary, thin and shining. A mucous dis- 
charge takes place from the canal and from the vagina. We are much 
inclined to consider this state as more truly deserving the name of 
chronic urethritis than that which Dr. Ashwell has so denominated, but 
which seems more of the nature of severe pruritus. 



MORBID CONDITIONS OF THE URINE. 

A brief resume of these, including urinary concretions, seems pro- 
perly to follow here. Urine is a fluid of amber color, of acid reaction, 
rather aromatic odor, quite clear and limpid, but depositing, after stand- 
ing some time, a delicate cloudy sediment, varying in specific gravity 
from 1015 to 1022, and amounting in the twenty-four hours to from 30 
to 40 ounces. Its quantity and its sp. gr., for the most part very in 
versely, so that in summer it is less abundant and heavier, in the winter 
more copious and lighter. The quantity of fluid taken of course influ- 
ences the quantity of the secretion; if fresh spring-water be drank 
early in the morning, upon an empty stomach, it will pass off with ex- 
traordinary rapidity by the kidneys, so that the quantity of urine passed 
will be treble or quadruple the normal. Opium, in some persons, a few 
other substances, and certain emotions, have the effect of producing an 
unusually aqueous urine, as well as the unknown cause of the disease 
now called polydipsia. 

The acidity of the urine varies very remarkably, according to the 
time which has elapsed since food was taken ; it is less acid, or even 
ilkaline, during digestion, especially of vegetable food, and becomes 
most acid when digestion has been finished for some hours. The urine 
is often alkaline from the presence of fixed alkali in healthy persons; it 
is important not to confound this condition, which will probably be re- 
placed by acidity some hours after, with alkalescence from carbonate of 
ammonia, which is always indicative of disease. The permanence of 
the blue color of reddened test-paper, which has been dipped in the 
urine, will distinguish the former condition from the latter. 

The limpidity of the urine is disturbed by a great variety of precipi- 
tates, which we shall presently notice. If the sp. gr. becomes very high, 



MORBID CONDITIONS OF THE URINE. 575 

the secretion at the same time not being diminished in quantity, it be- 
comes an indication of disease, probably of diabetes. Diminution of 
the sp. gr., on the other hand, the quantity not being temporarily 
rendered excessive by any of the causes mentioned, is also a sign of 
disease; it may be of M. Brightii, or polydipsia. 

The presence of sugar constantly in the urine constitutes the malady 
called diabetes, with whose true pathology we are as yet unacquainted; 
it seems, indeed, certain that in health the sugar in the blood is oxidized 
and converted into carbonic acid, while in diabetes the oxidizing process 
fails; but it does not appear that the proportion of carbonic acid ex- 
pired is diminished in this disease, which certainly, according to the 
theory, should be the case. Sugar is detected with great readiness by 
the test called Trommer's, which consists in the reduction of the hy- 
drated oxide of copper to the reddish-yellow sub-oxide, by the deox- 
idizing agency of the sugar. Oxide of silver may be used as a test in 
the same way, and will be reduced to the metallic state if sugar be 
present. It must be remembered that uric acid and albumen will act 
somewhat in the same way as sugar, and probably other substances have 
a similar effect, but this is not so rapid or decided as that produced by 
sugar. 1 

Albumen is often present in the urine in its soluble form, and is best 
detected by the addition of a few drops of nitric acid, which render it 
insoluble, or coagulate it, so that it falls down as a whitish precipitate. 
It is necessary to remember, that the addition of acid may cause a pre- 
cipitate of lithates, which is scarce distinguishable from that of albumen, 
except by being redissolved by heat ; it is, therefore, always desirable 
to boil the fluid after it has given a precipitate with acid. Rare cases 
may occur in which the albumen, though present in considerable quan- 
tity, is so modified that it does not yield the ordinary reactions. Dr. 
Bence Jones has described a substance of this kind, which did not pre- 
cipitate immediately by nitric acid, and when heated did not coagulate, 
nor was precipitated when nitric acid was added to the boiling urine. 

Chylous matter (so called) is occasionally present in the urine, but it 
appears that the essence of the disease does not consist in the flowing- 
off of chyle (from which the name is derived) constantly by the kidneys, 
but that, even during fasting, liquor sanguinis, with occasionally some 
trace of blood, escapes from the Malpighian tufts, and forms in the 
urine jelly-like coagula. In Dr. B. Jones's case, the influence of exer- 
cise in promoting and of perfect repose in preventing this unnatural 
drain from the blood was very marked, and showed clearly that it re- 
sulted from some peculiar defect in the organization of the Malpighian 
capillaries which rendered them unable to bear the increased stress of 
the somewhat excited circulation, without allowing more transudation to 
take place than was natural. The white color is due to the presence of 
oil in a finely-divided state, and is most abundant after food. Urine 
passed at this time forms sometimes a solid coagulum like blanc-mange, 
assuming the shape of the vessel in which it is contained. 

1 The only difference between ordinary diabetes (D. Mellitus, as it is termed), and the 
disease called D. insipidus, consists in the circumstance that the sugar, which is abund- 
antly present in the urine, is tasteless. In composition, it is identical with sweet sugar. 



576 



MORBID CONDITIONS OF THE URINE. 



The coloring matter of the urine is often of a much deeper tint than 
natural; this is chiefly the case in febrile disorders. In cachectic and 
exhausting diseases it often appears deficient, the urine appearing pale 
and wheyish. Urine of high color is often strongly acid, in moderate 
or diminished quantity, and tends to deposit uric acid crystals; it indi- 
cates, in some measure, a sthenic state of system. Urine, which is pale, 
is often alkaline or neutral, copious, more or less clouded by mucus or 
detached epithelium, and tends to deposit prismatic crystals of triple 
phosphate. This state is a faithful sign of asthenia. The color of the 
urine may be altered by haematin diffused through it; nitric acid and 
the microscope will then generally demonstrate the presence of albumen 
and blood-globules. Biliary pigment gives a remarkably deep tint to 
the urine, so that it is sometimes justly said to be like porter. This 
occurs, not only when there is actual jaundice, but generally when the 
liver is congested, and is a useful sign of this state. Its presence is 
demonstrated by the play of colors which takes place when nitric acid 
is added, the original tint passing through green, blue, violet, purple, 
to a pale red. 

Urine is occasionally met with of a blue color, and this, from the pre- 
sence of one of three different pigments, viz: cyanourine, indigo, and 
Prussian blue. It appears that these substances may be actually gene- 
rated in the economy, though the latter two, of course, may be derived 
from without. Their pathological relations are quite unknown, and we 
must refer for an account of their chemical habitudes to Dr. G. Bird's 
work. Nearly the same may be said of melanourine and melanic acid, 
which are black pigments, giving the urine an inky aspect. They are, 
probably, peculiar modifications of hsematin. 

Fig. 264. 




OOO 



Urinary deposits. 

(a) Various forms of uric acid. 

(b) Urates, pointed, globular, and molecular (common). 

(c) Triple phosphate, prismatic, and stellar forms. 

(d) Oxalate of lime, octohedra, and dumb bells. 

(e) Cystine. 

A great many vegetable coloring matters affect the urine, and it- 
should always be considered whether an abnormal tint of this fluid may 



MORBID CONDITIONS OF THE URINE. 



577 



not depend on the presence of one of them. Logwood, beetroot, and 
rhubarb are, probably, the most likely to be met with. 

The quantity of urea excreted varies according to the nature of the 
food taken and the amount of exercise. Lehmann, when living on an 
animal diet (thirty-two hen's eggs daily), found that his urine, in twenty- 
four hours, contained 819.2 grs. ; when a mixed diet was taken, the 
quantity was 500.5 grs.; when it was purely vegetable, the quantity 
was 346.5 grs. ; and when non-nitrogenous, it was only 237.1 grs. The 
quantity of uric acid varied similarly, though not in so great a degree. 
Exercise was found by Lehmann to increase the discharge of urea, lac- 
tic acid, phosphates, and sulphates ; it diminished, however, that of uric 
acid, phosphates, and sulphates. Dr. Prout has noticed two morbid 
conditions, which are often termed azoturia and anazoturia, distin- 
guished by an excess and deficiency of urea respectively. They are, 
probably, not so much essential maladies in themselves as symptomatic 
of certain disordered states of assimilation. Azoturia is detected by a 
formation of nitrate of urea taking place when nitric acid is added to 
the unconcentrated urine; it is not unfrequent in the oxalic acid di- 
athesis. The quantity of urea in diabetes is considerably increased; in 
M. Brightii it is, as we have seen, greatly diminished. 

Deposits of uric acid in crystals, or of its combinations with ammonia 
or soda, are exceedingly common. Now, with regard to these, it is first 
to be mentioned, that there are no certain evidences of an increased 



Fig. 265 




Fig. 267. 



6^ 











Fig. 268, 



Fig. 269. 



<? 





) /\ 




Fig. 270. 




Uric acid crystals 



exertion taking place. Dr. Bence Jones has shown that urine, which 
appears thick from a deposit of urates, may contain actually less uric 
acid than urine which remains clear, in the proportion of 0.52 to 0.87. 
The appearance of uric acid crystals depends on increased acidity of 
the urine, though we do not certainly know what is the cause of this ; 
37 



578 



MORBID CONDITIONS OF THE URINE. 



probably, however, the acid phosphate of soda. Three circumstances 
may occasion a deposit of lithates : (1.) An increased formation of them ; 
(2.) Increased acidity of the urine ; (3.) A low temperature. The pri- 
mary form of uric or lithic acid is the rhombic prism; but there are 
innumerable modifications of it, chiefly depending on an elongation of 



Fig. 271. 



Fig. 272. 



Fig. 273. 







^5 

E 




Fig. 274. 



Fig. 275. 



Fig. 276. 




Uric acid crystals. 

its long, and diminution of its short diameter, with rounding off of its 
angles, or on an approach to the rectangular form. The crystals often 
cohere in a radiated form. Their color is commonly a reddish yellow, 
derived from the urinary pigment, but they are, when pure, colorless. 
The common, so-called lateritious sediment, is in like manner colored 
by the pigment of the urine, and occurs sometimes nearly white. It 
consists of urate of soda, with small proportions of urate of ammonia 
and lime. This is positively stated by Lehmann, and we have satisfied 
ourselves of his being correct. Under the microscope, the deposit is 
seen to consist of minute granules, which cohere together in somewhat 
branching lines or shapeless masses. Occasionally, large opaque glo- 
bules are seen, and separate, needle-like crystals; or the latter are ob- 
served radiating from a centre, which may be constituted by one of the 
large globules. These forms, however, we have scarcely observed, ex- 
cept in urates of potash, soda, or lime, artificially prepared. Their 
ready solubility by heat, and the deposition of uric acid crystals on the 
addition of acid, are sufficient tests for all urates. The appearance of a 
sediment of lithates can, in many cases, scarcely be considered morbid; 
it results from some diminution in the cutaneous transpiration, some 



MORBID CONDITIONS OF THE URINE. 



579 



slight dyspepsia, &c. In febrile diseases, it is of very common occur- 
rence, especially in gout and rheumatism. It is, however, particularly 
to be observed, that, in acute gout, before the paroxysm, and in chronic 
gout, the quantity of uric acid in the urine is diminished, while it accu- 
mulates in the blood. (Lehmann and Garrod.) In various diseases of 
the heart and lungs which interfere with respiration, in cirrhosis of the 
liver, at the close of paroxysms of ague, the urine deposits a sediment 
of lithates abundantly. 

Phosphoric acid exists in the urine, combined with soda, ammonia, 
lime, and magnesia. The insoluble, earthy phosphates are held in solu- 
tion by the acid phosphate of soda. When the urine becomes alkaline 
from the presence of ammonia, a deposit takes place, which, if the alka- 
lescence be slight, consists of the monobasic phosphate of ammonia and 
magnesia (HO, NH 4 0, MgO) + P 2 5 ; if considerable, of the bibasic 
(NH 4 0, 2MgO) -f P 2 5 . The former is in the shape of separate pris- 
matic crystals, the latter of dentated laminae, radiating from a centre 
something like a star-fish. Simple star-like and penniform shapes of 
the monobasic salt are also described by Dr. G. Bird. Deposits of 



Fig. 277. 



Fig. 278. 





Fig. 279. 



Fig. 280. 





Earthy phosphates. 



phosphate of lime are occasionally met with as opaque, amorphous, 
granular sediments. The presence of any of the phosphatic deposits 
generally indicates a feeble and depressed state of system, with nervous 
irritation. The quantity of earthy and alkaline phosphates in the urine 
may be greatly increased, without the appearance of any deposit, or 
any tendency to alkalescence. Dr. Bence Jones states that the alkaline 
condition, with its frequent accompaniments of triple phosphate crystals, 
" has no relation of any sort or kind" to an increase in the total amount 
of phosphates. The disease in which these are most abundant is acute 






580 MORBID CONDITIONS OF THE URINE. 

inflammation of the brain; in delirium tremens they are remarkably de- 
ficient, if no food is taken. 

Oxalate of lime is not unfrequently found in the urine as a sediment 
which appears to the eye like a delicate mucous cloud, but is seen under 
the microscope to consist of multitudes of octohedral crystals, mingled 
in rare instances with dumb-bell forms. The pathological importance 
of a deposit of oxalates has been considered doubtful, and it is certain 
that it may easily be over-estimated. The conclusions which Mr. Coul- 
son adopts (p. 79, of his work on Diseases of the Bladder) we believe 
to be correct. These are, that the occasional presence of a few crystals 
is no indication of disease ; that the ingestion of aliments containing oxa- 

Fig. 281. Fig. 282. Fig. 283. Fig. 284. 

O 

n 

Oxalate of lime. 

lates may occasion a deposit of this kind ; that the same effect may be 
produced by sparkling wines or ales ; that such crystals are often observed 
in the urine of those suffering from acute rheumatism, and in that of 
persons with emphysematous lungs, or who are short-breathed from other 

Fig. 285. Fig. 286. 

Go 



§ ^ 

Dumb-bell crystals. 

causes ; that it is of very frequent occurrence at the commencement of 
convalescence from acute disease ; but that its constant presence in the 
urine of persons who are not to be included in any of the above classes, 
is a valuable symptom of a peculiar dyspepsia, generally attended with 
a remarkable train of nervous symptoms. 

Cystine, or cystic oxide, is of rather rare occurrence ; it is said to be 
of scrofulous and decidedly hereditary character. A patient of our own, 
whose urine contained an abundance of it for some time, was very eccen- 
tric, and had a sister affected with mania. It forms a whitish sediment, 
consisting of hexagonal tablets of various size, mixed in our case with 
much fatty matter. The tablets are often serrated at the edges, and 
contain some oily matter in their centres. 



a 



MORBID CONDITIONS OF THE URINE. 



581 



Fig. 287. 






o 



o 



n 



A. 



O 



Fig. 288. 



* Cft) 



(ft 



& (f) 



w' 



«&! ^ 






Fist. 289. 



A 



a 



O 



O 




Cystine. 



Carbonate of lime often occurs in the urine, in the form of an amor- 
phous powder, when it deposits phosphates ; it is produced by the de- 
composition of phosphate of lime by carbonate of ammonia, derived from 
the urea. 

Calculi are concrete masses, made up of one or more of the various 
substances we have mentioned, the several particles of which, if crystal- 
line, are held together by mutual attraction ; if amorphous, are united 



Fig. 291. 



Fig. 292. 





Lithic calculus. 



Section of a lithic calculus, showing the internal 
concentric layers. 



together by some animal matter. Thus Dr. Walshe states the case, and 
no doubt correctly ; but we have recently examined a small calculus, 
which consisted of octohedra of oxalate of lime, united together by a 



582 



MORBID CONDITIONS OF THE URINE, 



considerable quantity of mucus, in which they were imbedded. The 
following description of the several varieties of calculi is an abbreviation 
of Dr. Prout's : (1) The lithic acid calculus is generally of a brownish- 
red, or fawn color, sometimes approaching that of mahogany. Its outer 
surface is commonly smooth, the sectional displays numerous concentric 
laminae. Its shape is generally ovoid ; its size very various; it is the 
commonest species ; dissolves completely in liquor potassse, and in nitric 
acid with heat, the dry residuum presenting a beautiful pink color. (2) 
Lithate of ammonia calculus is of a clay color, composed of concentric 
layers ; its outer surface smooth, or slightly tuberculated ; its sectional 



Fig. 293. 



Fig. 294. 





Oxalic or mulberry calculus. 



Internal structure of the same. 



marked by concentric layers. It chiefly occurs in children under 
puberty, and hence is generally small, and rather rare. It behaves in 
several respects like the preceding, but is more soluble in water, and 
gives off ammonia when heated with caustic potash. (3) The oxalate of 
lime calculus is generally of a dark-brown color, from adhering and 





Cystic calculus. 



Internal structure of the same. 



altered blood, but may be pure white. Its surface is rough and tuber- 
culated (mulberry), its texture is hard and laminated. When heated it 
is decomposed, the acid being destroyed, and an alkaline ash (lime) re- 
maining. Heated in a tube with sulphuric acid, carbonic acid and car- 
bonic oxide gases are given off, and may be recognized by the former 
being absorbed by liquor potassse, and the latter burning with a blue 
flame. (4) The cystic oxide calculus is of a yellowish-white ; its surface 
is smooth, and of a crystalline aspect. It is not laminated, but appears 



MORBID CONDITIONS OF THE URINE. 



583 



to be made up of a multitude of irregularly aggregated crystals, and has 
internally "the color and shining look of beeswax." It is soluble both 
in acid and alkalies, and crystallizes in hexagonal tablets from its am- 
moniacal solution. (5) The phosphate of lime calculus is of a pale-brown 
color, and smooth porcelaneous surface. It is regularly laminated, and 
the laminae are vertically striated. It is not common, and does not 



Fig. 297. 



Fig. 298. 




Phosphatic calculus. 



Ammonia magnesian calculus. 



attain a large size ; is soluble in hydrochloric acid, and precipitated 
from its solution by liquor ammoniae as a white powder. (6) Phosphate 
of ammonia and magnesia calculus is nearly white, its surface is uneven; 
it is friable, and not laminated, except in some rare instances, when it 



Fig. 299. 



Fig. 300. 





Fusible calculus. 



Internal structure of the same. 



is hard, crystalline, and more or less transparent and laminated. It 
yields ammonia when heated, fuses with difficulty, is soluble in dilute 
hydrochloric acid, and is precipitated from this solution by ammonia as 
prisms or stellse. (7) The fusible calculus, a mixture of the two preced- 
ing, is whiter and more friable than any other, often of very large size, 
and occurs^ frequently. It melts readily, is soluble in dilute hydrochloric 
acid, and its ammoniacal precipitate consists of amorphous particles 



584 MORBID CONDITIONS OF THE URINE. 

and stellar crystals. (8) The alternating calculus is made up of two or 
more layers of different urinary deposits, as seen in the following exam- 
ples ; a nucleus of uric acid may exist with a covering of urates, oxalate 
of lime, or phosphates — the nucleus may be oxalate of lime with a cover- 
ing of uric acid, urates, or phosphates ; a nucleus of uric acid may be 
covered by oxalate of lime, and this by mixed phosphates, or the latter 
may be replaced by uric acid ; again, a nucleus of oxalate of lime may 
be covered by uric acid, oxalate of lime, and phosphate of lime in suc- 
cession. More than half the whole number of calculi are alternating, 
and it is especially to be observed, that, in a very great proportion of 
instances, the outer crust consists of phosphates ; so that Dr. Prout has 
stated it as a law, that a decided deposition of the mixed phosphates is 
not followed by any other. (9) The carbonate of lime calculus is very 
uncommon ; it is perfectly white, and very friable. We think it is occa- 
sionally found as a coating to renal calculi, being thrown out from the 
irritated mucous membrane. In one such case it appeared under the 
microscope as grains and round globules, about the size of those of the 
blood ; it effervesces strongly with acid, and the lime after neutraliza- 
tion with ammonia can be precipitated by oxalate of ammonia. (10) 
Uric or xanthic oxide calculi are very rare ; they are of a light-brown 
color externally, "and of a brownish flesh-color in their interior;" their 
surface is smooth and polished ; they consist of concentric layers, and 
assume a waxy lustre on being rubbed. For its chemical characters we 
refer to Mr. Coulson's work, p. 282. (11) The fibrinous calculus is of 
small size, of amber color, and waxy consistence, and is probably only 
indurated fibrin, or mucus, therefore not a true urinary concretion. 



CHAPTER XXXYI. 

ABNORMAL CONDITIONS OF THE MALE GENERATIVE 

ORGANS. 

Testicles and vasa deferentia. — There is no sufficient evidence to show 
that more than two testicles ever exist. They are absent when the en- 
tire sexual apparatus is wanting, and in some rare cases they are im- 
perfectly formed, or one only may exist. An apparent absence of one 
or both glands at birth is not very unfrequent, the descent of the organ 
being arrested or delayed, so that it lies in the groin, the inguinal canal, 
or the lower part of the abdomen. Of one hundred and three male 
infants examined by Wrisberg at the time of birth, seventy-three had 
both testicles in the scrotum; while in twenty-one, one or both were in 
the groin, and the remainder had one or both in the abdomen. He 
found the imperfection more frequently on the left than on the right side, 
in the proportion of seven to six. Mr. Curling believes that if the de- 
scent does not take place within twelve months after birth, it is seldom 
fully and perfectly completed afterwards without being accompanied by 
hernia. The reason of this is sufficiently apparent, the pressure of the 
muscular walls of the abdomen must tend to cause the descent of the 
intestine through the open inguinal canal. When the testicle is still in 
the abdomen at birth, it may descend, and usually does, within a few 
weeks (it did so in ten out of the twelve cases mentioned by Wrisberg), 
or it may not descend till some time before puberty, or it may not appear 
at all. The cause of the testis remaining in the abdomen is considered 
by Mr. Curling, with much probability, to be owing either to paralysis 
and defective development of the cremaster muscle, or to the contraction 
of adhesions between the gland and some adjacent viscus. The disco- 
very of the continuation of muscular fibres from the fixed attachment 
of the cremaster up along the gubernaculum to the testis in its primitive 
situation by the side of the vertebral column, inclines us strongly to be- 
lieve that these fibres must be the agents in causing the descent of the 
gland into its appointed place. Contraction of the external abdominal 
ring is also mentioned as one of the causes impeding the descent of the 
testis. In rare instances, the testis wanders into other situations ; one 
has been found in the perineum, the other being normally placed; and 
in two instances a testicle has preferred to make its exit by the crural 
instead of the inguinal canal. Sometimes it happens that the gland is 
turned round in the scrotum, so that its anterior face becomes posterior. 
It is quite ascertained that the abnormal situation of the testes in the 
abdomen is by no means inconsistent with the full discharge of their 



586 ABNORMAL CONDITIONS OF THE 

function. Cases are occasionally met with in which the glands remain- 
ing in the abdomen have been small and undeveloped; but this imper- 
fection could not be dependent on the unnatural position, as the analogy 
of animals and positive observation in men shows. 

The vas deferens may be absent in a greater or less extent, and even 
the epididymis has been found in great part deficient. What is very 
remarkable is, that in several of these cases the testicle was fully formed, 
and though incapable of fulfilling its function, was scarcely less than the 
other. Experiments on animals have also shown that obliteration of 
their excretory ducts does not cause necessarily atrophy of the testes, 
nor efface in the individual the characteristic marks of the male sex. 
The most usual and least degree of this imperfection is that the vas de- 
ferens terminates in a blind extremity before reaching the vesicula semi- 
nalis. There is no such condition known as true hypertrophy of the 
testes; the gland may become greatly enlarged when attacked with 
inflammation, or when it is the seat of morbid growths ; but while in the 
fullest activity of its function it does not exceed the normal size. This, 
no doubt, depends on its secretions, which of course may be formed in 
very varying quantities, rapidly passing of by the excretory duct. An 
increased production of semen by the testis would correspond to apparent 
hypertrophy of the thyroid by dilatation of its cavities. 

Atrophy of the testis, either congenital from defective development, 
or acquired, is not unfrequent. Several instances are mentioned by 
Mr. Curling, in which the penis and testicles of persons arrived at the 
age of puberty, or of adults, did not exceed the size of those of child- 
ren ; two of these were of weak mind, but this condition is by no means 
the frequent accompaniment of cretinism or idiocy. A case recorded by 
Mr. Wilson shows the influence of aroused mental emotions in producing 
the due development of the generative organs, which had not taken 
place at the twenty-sixth year of age. The atrophy of the testis in 
old age comes on very gradually, the organ becomes flabby, and its tis- 
sues discolored, but is often little diminished in size. 

Mr. Curling states that the ordinary weight of a sound testicle, in a 
healthy adult, is about six drachms, great individual differences, how- 
ever, being often met with, as well as differences between the two glands; 
the left was heavier than the right in five cases out of six. If the weight 
fall below three drachms, the organ may be certainly said to be in a 
state of atrophy. " A testicle in an advanced state of wasting, not 
arising from disease of the gland, usually preserves its shape, but feels 
soft, having lost its elasticity and firmness. Its texture is pale, and 
exhibits few bloodvessels ; the lobuli and septa dividing the lobes are 
indistinct, and the former cannot be so readily drawn out into shreds 
as before. The epididymis does not usually waste so soon, nor in the 
same degree, as the body of the testicle. It sometimes, however, loses 
its characteristic appearance; and I have even found it reduced to a few 
fibrous threads. The fluid pressed out of the wasted testicle and epi- 
didymis is entirely destitute of spermatic granules, and spermatozoa. 
In many instances, adipose tissue is deposited behind the tunica vaginalis, 
and encroaches on the epididymis and the posterior part of the testicle. 
Patty matter is also found in the glandular substance of atrophied tes- 



MALE GENERATIVE ORGANS, 



587 



tides. The structures composing the spermatic cord undergo a corre- 
sponding diminution, the cremaster muscle disappears, the nerves shrink, 
and the vessels are reduced in size and number. The vas deferens, 
though small, can generally be injected with mercury as far as the com- 
mencement of the epididymis. The testis of a man, aged thirty-four, 
dying of scrofulous disease of the lungs and kidneys, weighed little more 
than two drachms. The vas deferens and epididymis appeared healthy. 
The wall of the tubes had a fibroid aspect, and there were numerous fibre- 
forming nuclei on their surface. Their epithelial lining was everywhere 
in a state of fatty degeneration ; it was reduced to atrophied, sometimes 
fattily degenerated, nuclei, and small corpuscles made up of oily mole- 
cules. The aspect of the gland tissue was dirty yellow; it was soft and 
flaccid. A testicle atrophied from disease is not only of diminished size 
and weight, but is altered in shape, being uneven and irregular, and 
sometimes of an elongated form. The surfaces 
of the tunica vaginalis are adherent, and its ca- 
vity is partly or entirely obliterated. There is 
no, or very little, trace of the proper glandular 
structure, the organ being converted into fibrous 
tissue of a firm texture. It loses its peculiar 
sensibility to pressure, but is sometimes the seat 
of morbid sensibility." The causes of atrophy 
of the testis are very various: deprivation of its 
supply of blood from obliteration of the sperma- 
tic artery, injuries of the spinal cord, producing 
paraplegia, and probably therewith the loss of 
the nervous influence necessary for the gland, 
inflammation of its tissue, over-excitement of the 
organ, the long-continued use of iodine, which is 
said to affect the female breast similarly, tuber- 
cular elephantiasis, injuries to the back of the 
head and nape of the neck, the pressure of 
effusions, and of large herniae, neuralgia — all 
appear, on good evidence, to be real causes of 
atrophy of the part in question. The most com- 
mon cause is inflammation; and it is easy to un- 
derstand how the effusion of fibrin within the 
unyielding capsule of the gland should compress and obliterate 
bloodvessels, as well as the tubuli seminiferi themselves. 

The serous covering of the testis, the tunica vaginalis, is liable to be 
attacked by acute inflammation, and then suffers as other serous mem- 
branes do. The membrane becomes thickened and injected with blood, 
and is coated with a more or less considerable quantity of fibrinous 
exudation. Serum is at the same time effused into the cavity, and is 
rendered turbid by flakes of fibrin floating in it. The exudation may 
take the form of pus, but this rarely occurs. The unabsorbed fibrin 
very commonly forms adhesions between the opposing surfaces, which, 
in time, become very firm and dense, and may obliterate the cavity. It 
is by no means rare to find adhesions, to some extent, in the tunica 
vaginalis ; Mr. Curling observed such in nine out of twenty-four in- 




Inflammation of tunica va- 
ginalis, after application of 
caustic; the aperture made by 
this is shown at*. There are 
flocculi of lymph on the serous 
surface of the testis. — From 
Mr. Curling's article. 



the 



588 



ABNORMAL CONDITIONS OF THE 



Fig. 302. 



stances. The epididymis is prone to partake in the inflammation of the 
tunica vaginalis, and vice versd. 

Hydrocele is a dropsy of the serous covering of the testis, and does 
not differ essentially from dropsies of other serous sacs. The fluid is 
usually clear, and of a straw color, sometimes turbid, with albuminous 
flocculi, and not unfrequently contains a considerable quantity of shining 
particles of cholesterin. Its quantity is sometimes very considerable ; 
six quarts are said to have been withdrawn in the case of Gibbon. The 
serous membrane in old hydroceles may be more or less thickened, and 
even the seat of calcareous deposit. Adhesions formed between the two 
layers of the tunica vaginalis may, according to their length and extent, 
alter the usual position of the testicle, so that it appears in front, 
instead of lying at the posterior and lower part of the distended sac ; or 
they may subdivide the cavity, and produce thus a multilocular hydro- 
cele. The natural cul-de-sac which exists between the epididymis and 
the body of the testicle, on the outer side, is 
sometimes much distended, so as to form a pouch, 
which projects on the inner side of the gland. 
The morbid action in hydrocele is confined to 
the serous membrane ; the testis either remains 
natural, or is somewhat flattened, and, in some 
cases, partially atrophied by the pressure of the 
fluid. When, however, the original seat of dis- 
ease is in the gland itself, the serous covering is 
often secondarily involved, so that serous effusion 
in the sac very often is associated with chronic 
orchitis, or other diseases of the testicle. This 
combination is termed a hydro-save ocele. There 
is contradictory evidence on the question, whether 
hydrocele is more common on the right, or on 
the left. Mr. Curling's observations show that 
the right side is most often affected. 

In congenital hydrocele the dropsical tunica 
vaginalis retains its foetal communication with 
the peritoneal cavity. 

Encysted hydrocele, as it is called, proceeds 
from the development of new cysts beneath the 
serous membrane. These are exactly similar to the simple cysts we 
have described, p. 183, having a wall of thin fibrous tissue, and a lining 
of tessellated epithelium, with usually limpid, fluid contents. They may 
be situated : (1) " beneath the visceral portion of the tunica vaginalis, 
investing the epididymis; (2) between the testicular portion of the 
tunica vaginalis and the tunica albuginea, which are thus separated 
from each other ; (3) between the layers of the loose or reflected portion 
of the tunica vaginalis." In the two last-mentioned situations they 
rarely occur. When formed on the epididymis, they sometimes carry 
the serous membrane outwards as they enlarge, so that they become 
pedunculated, just as the small serous cysts in the neighborhood of the 
ovary often do with the peritoneum. Mr. Curling states that these 
pedunculated cysts do not acquire a large size, seldom exceeding that 




Drawing of large hydrocele, 
combined with scrotal hernia. 
— Curling's Art. on Testis, Cy- 
clop* An at. and Phys. 



MALE GENERATIVE ORGANS, 



589 



of a currant. Several cysts may coexist in the same gland, and, when 
opened, produce the appearance of a sacculated arrangement. The 
walls of the cysts are liable to inflammation, which causes their contents 
to be mingled with various exudations of serum, fibrin, or even blood. 
Spermatozoa are very frequently present in the fluid of encysted hydro- 
celes, to which they impart a milky or opaline opacity. They subside 
to the bottom of the vessel, where the fluid is left at rest, leaving the 
upper portion more transparent, but containing some albumen, which is 
not found in the limpid contents of ordinary cysts of this kind. It 
is extremely probable that they make their way into the cysts in 
consequence of rupture of some seminal canal lying in contact with 
them, just as a biliary duct sometimes opens into the sac of an hydatid. 
This opinion is confirmed by the circumstance that patients generally 

Fig. 303. 




Encysted hydrocele of tunica vaginalis.— From Mr. Curling's article. The cyst is between the tunica 
albuginea and the tunica vaginalis of the testis. 



report the swelling to have commenced after some injury to the testicle. 
Spermatozoa are rarely, if ever, present in the fluid of common hydro- 
cele. In one case, a few seemed to have escaped into the general 
cavity, from the rupture of a small cyst. 

Diffused hydrocele of the spermatic cord is a rare affection. It con- 
sists in the enlargement of the cells of the areolar tissue, and their dis- 
tension with a white or yellowish serous fluid. The inclosing fascial 
sheath is condensed and thickened, and at the lower part of the swelling, 
which is always the largest, separates it completely from the tunica 
vaginalis. The nature of the disease does not seem to be sufficiently 
ascertained. Mr. Curling classes it with simple oedema ; we should be 
more inclined to regard it as a chronic inflammation. 



590 



ABNORMAL CONDITIONS OF THE 



Encysted hydrocele of the spermatic cord forms a tumor, of oval 
shape, and seldom attaining the size of a hen's egg. It is loosely 
attached to the vessels of the cord which pass behind it. Instead of 
there being only one cyst, there may be several, forming a series along 
the cord. This circumstance indicates their origin, from the partially 
obliterated process of peritoneum, which is carried down with the tes- 
ticle in the formation of the tunica vaginalis. According to another 
view, they are simple cysts, of new production, analogous to those which 
constitute encysted hydrocele of the testis. It may be mentioned that 
simple hydrocele occurs not unfrequently together with some of the 
other varieties, and also with inguinal hernia. 

Hsematocele is the term applied to a tumor formed by an effusion of 
blood from the vessels of the testis, or of the spermatic cord. Its most 

Fig. 304. 




Hematocele: tunica vaginalis greatly thickened ; testis pretty healthy. — From Mr. Curling's article. 

common seat is in the tunica vaginalis, which may be so greatly distended 
as to exceed the size of the adult head. The blood undergoes various 
changes, coagula being formed, sometimes in separate masses, sometimes 
in firm layers, as in the walls of an aneurism. The fluid part, in old cases, 
is more or less thick and grumous, sometimes resembling coffee-grounds. 
The presence of the blood occasionally excites inflammation, leading to 
fibrinous and serous effusion, and, it may be, to suppuration. The effused 
blood sometimes putrefies, offensive gases are produced, and, unless free 
exit be given to the decomposed matter, fatal gangrene takes place. The 
tissues surrounding the tunica vaginalis are apt to become involved in the 
inflammation, though they are affected in a more chronic manner, and 



MALE GENERATIVE ORGANS. 591 

thus the walls of the serous cavity are considerably thickened, perhaps 
so as to be half an inch in diameter. The testicle usually remains 
unaffected, except that in old cases it is atrophied from pressure. An 
encysted hydrocele of the testicle or epididymis may be converted into 




Bruise of the scrotum, a form of hematocele.— Liston. 



an hsematocele, by the effusion of blood into its cavity. So, also, may 
the encysted hydrocele of the cord. Both these, however, are rare 
affections. 

Diffused hematocele of the cord results from the rupture of some 
vessels of the cord, which are, probably, in some way diseased {e.g. 
varicose), in consequence of which blood is effused, in greater or less 
quantity, within the spermatic fascia; and, if the bleeding continues, or 
recurs after an arrest of varying length of time, a tumor of enormous 
size may be formed, reaching down even to the knees, as in a case 
recorded by Mr. Bowman, in the Medico- Chirurgical Transactions, vol. 
xxxiii. The cause of the rupture is generally some straining effort. 

Orchitis (op*t$, a testicle), may be either acute or chronic. The acute 
disease is sometimes primary, as when the testis has suffered from ex- 
ternal violence ; more often it is consecutive, extending along the vas 
deferens, to the epididymis and testis. In the latter case, the disease 
has been called epididymitis, from this part being chiefly and most con- 
stantly affected. Opportunities rarely occur of examining the gland 
when acutely inflamed, but the following appearances have been observed: 
The testis itself is not much enlarged, owing to the unyielding nature 
of the tunica albuginea; its vessels are congested, so that it has a darker 
tint than natural. The epididymis is enlarged, especially at the lower 
part, to twice or three times its natural size, "and feels thick, firm, and 
indurated." This enlargement depends on the presence of exudation- 
matter. "The coats of the vas deferens are thickened, and the adja- 
cent vessels injected. The tunica vaginalis is inflamed, and its cavity 
contains the usual effusions. Suppuration rarely occurs in the body of 
the testis in consecutive orchitis, it is more frequent in primary; indeed, 
in the former, it is not uncommon for the gland itself to escape entirely. 
When pus has been formed in the testis, it does not easily make its way 



592 ABNORMAL CONDITIONS OF THE 

out, and consequently burrows in different directions, disorganizing the 
tissue of the gland. Sometimes, when all active inflammation has sub- 
sided, the fluid part of the pus becomes absorbed, and the remainder 
passes into the state of a concrete, whitish mass, much resembling crude 
tubercular matter. It may, however, be distinguished from this, by being 
contained in a cyst, and by the condition of the adjacent glandular tissue, 
which is more altered from its healthy state than it is in the neighbor- 
hood of tuberculous deposit. The color of the yellow exudation in chronic 

Fig. 306. 




Acute orchitis, attendant on gonorrhoea. 

orchitis, and its relation to the tubuli, serve to distinguish it also from 
concrete pus. Another result of inflammation of the testis is wasting 
of the gland, occasioned by the interstitial fibrinous exudation passing 
into fibroid tissue, and compressing the bloodvessels and tubuli. The 
enlargement of the epididymis not unfrequently subsides very incom- 
pletely, leaving an indurated, knotty swelling, situated usually at its 
lower part. The fibrinous matter which imbeds the duct and the areolar 
tissue in this part, does not cause the obliteration of its canal, which is 
even sometimes considerably dilated, as Mr. Curling has observed, so as 
to be four or five times its usual dimensions. "In old cases, the epi- 
didymis acquires the density and consistence of cartilage, and sometimes 
even of bone." "The coats of the vas deferens are also found, for some 
extent, thickened and indurated." 

Chronic orchitis is characterized by the effusion of a yellowish, homo- 
geneous looking matter, in the substance of the testicle. This matter, 
when first formed, is soft, but afterwards becomes firm and solid, and 
intimately blended with the glandular tissue. It may occur as a single 
deposit, or as several coexisting in the same gland. These enlarge and 
coalesce, until they occupy the whole organ, giving it a uniform yellow- 
ish white appearance. In some cases, the epididymis is attacked by 
the same deposit, but, in the majority, it escapes. The seat of the yel- 
low matter seems to be the interior of the tubuli. Mr. Curling, describ- 



MALE GENERATIVE OEGANS. 593 

ing the condition of a specimen which he examined after injection of the 
bloodvessels, says, that at the anterior part of the testicle the deposit 
appeared as round, isolated bodies ; " about the centre it assumed a 
beaded arrangement, and towards the mediastinum formed a number of 
closely-set yellow lines, or processes, radiating towards the posterior 
part of the testicle, where they were amalgamated into one uniform 

Fig. 307. 




Chronic orchitis, with fungous protrusion of testis. — From Mr. Curling's article. 

mass." The deposit is usually considered, and we believe with justice, 
as of scrofulous nature, but Mr. Curling speaks confidently of its being 
coagulable lymph. 

As the yellow deposit increases, it often causes adhesion of the two 
layers of the tunica vaginalis, as well as of these to the skin, and at the 
same time occasions ulcerative absorption of these layers, and of the 
tunica albuginea, so that, at last, a fungous protrusion of the affected 
tissue takes place. This projecting growth presents an ash or yellowish- 
white appearance, varied by irregular patches of a pale red hue, and 
sometimes of black. It is closely girt by the scrotum, the ulcerated 
edges of which are often thickened and everted. The fungous protrusion 
is not peculiar to chronic orchitis alone, a similar one may take place 
whenever inflammation of the gland has produced ulceration of the tunica 
albuginea, the softened and tumefied tissue within escaping at the open- 
ing, much as the brain does when hernia cerebri occurs from giving way 
of the dura mater. The result of chronic orchitis maybe different to the 
above, but equally destructive of the efficiency of the gland. The in- 
flammation, after it has given rise to a considerable amount of deposit, 
may subside, and the gland remain for a long time somewhat enlarged 
and indurated, but not painful. The deposit at last contracts and 
shrinks, inducing gradual atrophy of the testis, which may be reduced 
to a mere nodule, chiefly consisting of dense fibroid tissue, scarce larger 
than a nut. In these cases the epididymis often remains tolerably 
healthy, but is sometimes rendered " nodose, irregular, and hard." 

Purulent deposits have been found in the testicle, apparently, as the 
result of pyaemia, in connection with synovitis of the shoulder-joint and 
lobular pneumonia. A preparation of this kind is in the Museum of St. 
George's Hospital. 

Tubercle is not very infrequent in the testis ; situated sometimes in 
38 



594 ABNORMAL CONDITIONS OF THE 

the body of the gland, but more often in the epididymis. In the for- 
mer site, it appears as a single or as several masses of opaque yellow 
matter, which may increase, so as to occupy almost the entire gland — 
a thin layer of glandular tissue alone remaining around the morbid 
mass; on the tubercle softening and breaking down, a cavity may be 
formed, which ulcerates and discharges its contents externally through 
the scrotum. In the Museum of St. George's, there is a preparation 
which shows extremely well the cavity of a large scrofulous abscess of 
this kind, with a thick layer of tuberculous matter forming its wall. 
This is exactly analogous to a tuberculous cavity in the lungs. Mr. 
Curling gives a drawing of a specimen in which the epididymis was oc- 
cupied by tubercular deposit in its whole extent, while the body of the 
testis remained perfectly sound. Cretaceous matter is occasionally 
found in the testis, which is doubtless the residuum of tuberculous de- 
posit, which has softened and undergone calcareous change. It resem- 
bles exactly that which is found in the lungs and in the bronchial glands. 
Some uncertainty prevails respecting the actual site of tubercle in the 
testicle. Dr. Carswell regards it in this part, as elsewhere, to be formed 
on the free surface of mucous canals, or their continuations. Mr. Curl- 
ing's conclusion we believe to be the more correct, that it may be depo- 
sited both interstitially, as well as within the tubuli. The tunica vagi- 
nalis is frequently inflamed when there is tuberculous deposit in the 
testicle. Pulmonary tubercle, or general tuberculosis, is present in 
many cases of similar disease of the testis. 

Cancer is common in this part, and is most frequently primary. The 
scirrhous variety is occasionally met with, but is very rare; "it is cha- 
racterized by its slow progress, as by its great induration." JZncepha- 
loid is the ordinary form of orchitic cancer ; it commences as one or 
two masses among the tubuli, which it gradually destroys, as it accumu- 
lates. Whether it advances by infiltrating the tissue, as well as by 
pushing it aside, does not seem quite determined ; the latter, however, 
seems to be the more common occurrence. As it increases in size it 
causes absorption of the tunica albuginea, which gives way, and allows 
the growth to sprout out, and to vegetate freely in the scrotum, which 
it distends sometimes to the dimensions of a foetal head. The scrotum 
does not soon become involved in the disease, and ulcerated, probably 
in consequence of its distensile nature and loose connection with the 
testis. " The epididymis remains for some time unaffected." In one 
case, mentioned by Mr. Curling, its tubes were found filled with can- 
cerous matter. Great enlargement of the vessels takes place; the sper- 
matic artery has been observed as large as the radial. The spermatic 
cord becomes invaded by the disease, and sooner or later the lumbar 
glands, and perhaps the inguinal, become affected, while secondary can- 
cers spring up in various parts. Encephaloid has been known to attack 
the testis in the first year of life, but is most common about the middle 
period. Its duration is very variable, from a few months to several 
years. Colloid cancer and melanotic have very rarely been observed in 
the testis. The tunica vaginalis is said to have been affected with fun- 
goid (cancerous) disease, the testis remaining healthy. 

Cyst-production sometimes takes place in the substance of the testis 



MALE GENERATIVE ORGANS. 



595 



in a very marked manner. The cysts may be only two or three in 
number, or excessively numerous, causing considerable enlargement. 
They vary in size, from the most minute to the dimensions of a pigeon's 



Fig. 308. 



&\ 



6 



*m 



wm 



«mm 












/ 






: -^^S? : '^^l 2^ 



Section of cystic sarcoma of the testis. — After Mr. Curling. 

egg. Their contents are, in the younger cysts, a transparent, light- 
colored fluid — in the older, a more thick, viscid, and very albuminous. 
The cysts are sometimes imbedded in solid stroma, probably of fibroid 
tissue ; sometimes small masses of enchondroma are developed between 
them. A lobulated growth sometimes arises from the wall of the cyst, 
and occupies its cavity more or less completely. In one specimen we 
have examined, the contents of the cysts were not identical ; in some, 
which appeared as opaque white spots, they consisted of layers of scaly 
epithelial particles, more or less flattened and pressed together; in 
others, the contents were a pulpy mass of swollen scales, with very 
abundant amorphous and oily matter, and small, delicate vesicular glo- 
bules; others again contained a clear fluid, and a soft, whitish pulp, 
consisting almost entirely of small oil-laden, granulous vesicles. The 
stroma inclosing the cyst cavities consisted of a dense fibroid substance. 
Hemorrhage may take place into a number of the cysts at different 
places, as is well seen in a beautiful specimen of the disease in St. 
George's Museum. In this case, the testis was inclosed in a common 
covering — probably the tunica albuginea — along with the tumor, and 
lay at one side of it; in other cases, the glandular structure is expanded 



596 ABNORMAL CONDITIONS OF THE 

over the growth. There was no contamination of the glands, nor, as 
far as known, any return of the disease in the patient from whom the 
tumor just mentioned was removed ; but in other cases of cystic disease 

Fig. 309. 




€Mik>t 






Contents of various cysts in the case referred to in the text. 
Tn the lowest figure, the epithelial scales are flat and opposed to each other; in the middle, the epithelial 
scales are much swollen, and mingled with granular matter and corpuscles. 

the removal of the part has been followed by development of cancer in 
other localities. These latter are probably instances of the combina- 
tion of cyst-production with cancer. 

Loose bodies are occasionally found in the tunica vaginalis, similar to 
those occurring in joints. They are, in all probability, masses of exuded 
fibrin, and have, at least in the majority of cases, no claim to the epithet 
cartilaginous, which is often given to them on account of their external 
appearance. Calcareous matter is sometimes deposited in them ; and 
Mr. Curling has observed the presence of laminae similar to those of 
bone. The remains of a foetus have been found in the scrotum, in con- 
nection with the testicle. This seems to have resulted from the inclusion 
of a second atrophied embryo in the abdomen of the first, from which it 
passed out with the testicle into the scrotum. 

Morbid dilatation of the spermatic veins constitutes varicocele. In 
an advanced stage of the disease, the coats of the veins are thickened, 
so that they do not collapse when cut across. " The enlarged veins hang 
down below the testicle, and reach upwards into the inguinal canal; and, 
when very voluminous, conceal the gland, encroach on the septum, and 
extend to the other side of the scrotum." The veins in the interior of 
the testis itself, and those on the surface beneath the serous membrane, 
also become enlarged. The left veins are oftener affected than the right 
— partly in consequence of accumulation of harder fecal matter in the 
descending colon than in the ascending, partly on account of the left 
spermatic vein opening at right angles into the renal, and partly, per- 
haps, from the lower position of the left testis. When the varicocele is 
slight, it does not impair the nutrition of the testis ; but, when large, it 



MALE GENERATIVE ORGANS. 597 

occasions very marked atrophy — doubtless, in consequence of the in- 
creased venosity of the retarded blood. 

Fatty tumors are occasionally developed in the spermatic cord. 

It may be well to notice here the morbid conditions of the scrotum, 
as a portion of integument which has somewhat peculiar relations. It 

Fig. 310. 




Hypertrophy, or elephantiasis of the scrotum, in a Hindoo. 

is one of the most frequent situations of elephantiasis — a disease which 
M. Cazenave regards as essentially connected with inflammation of the 
lymphatics of the part. This produces the most enormous enlargement 
of the part — such that the mass has been known to weigh 200 pounds 
more than the weight of the rest of the body. The epidermis, the corium, 
and the subcutaneous areolar tissue, are all, especially the latter, greatly 
hypertrophied. The areolar tissue is converted into a large mass of 
fibrous material, infiltrated with an albuminous and fibrinous fluid. Its 
areolaa are much enlarged in some parts; the testes remain sound; the 
spermatic cords are elongated several inches, owing to the testicles being 
dragged down, but are not otherwise diseased. Hydrocele sometimes 
occurs. When the disease is confined to the scrotum, and the enlarge- 
ment becomes very great, "the penis becomes drawn in, and ultimately 
disappears, while the elongated prepuce is continuous at a navel-like 
opening in the skin of the surface of the tumor." 

Common hypertrophy of the integument of the scrotum sometimes 
occurs ; in this, there is no alteration of the subcutaneous tissue. 



598 ABNORMAL CONDITION'S OF MALE GENERATIVE ORGANS. 



Epithelial cancer is the common form in which it appears in the 
scrotum, constituting what is commonly called chimney -sw eep er' s can- 
cer, on account of its being apparently produced by the contact of soot. 
It is very remarkable that the disease may not appear for many years 



Fig. 311. 



Fig. 312. 





An aggravated example of chimney-sweeper's can- 
cer ; much superficial texture destroyed. 



Corpuscles from chimney-sweep's cancer. 



after the person has ceased entirely to be in any way exposed to the 
influence of soot. Mr. Curling mentions a case in which a man, after 
having been a sweep, went to sea, and led a sailor's life for nineteen 



Fig. 313. 



Fig. 314. 





Enlarged prostate. 



Hypertrophy of prostate. 



years before the disease made its appearance. It is, of course, possible 
that, in these and similar cases, the cancerous development and the 
sooty employment were mere coincidences. Cancer of this kind does not 
show much tendency to contaminate the lymphatic glands or distant 
parts. Even the glands in the groin are not always affected, and those 



ABNORMAL CONDITIONS OF THE PROSTATE GLAND. 599 

in the interior of the abdomen very rarely. The disease advances by 
invading the adjacent tissues, and thus produces fearful ulceration, ex- 
tending even to the groin and thigh, and destroying life by perforating 
the coats of some of the large vessels. 

A case of melanotic cancer of the scrotum has been observed by Mr. 
Curling. 

Fibrous tumors are sometimes developed in this part, and may form 
a large mass when several are grouped together. 



ABNORMAL CONDITIONS OF THE VESICUL.E SEMINALES. 

They participate in the defective development of the testes, being ab- 
sent or imperfect when their related glands are so. Chronic catarrhal 
inflammation not uncommonly attacks the vesiculae, causing tumefaction 
of their mucous membrane, secretion of unhealthy mucus, dilatation of 
the cavity, and thickening of its parietes. Ulcerative destruction of the 
mucous membrane occasionally takes place, the result of which may be 
thickening and cartilaginification of the parietes (the morbid action hav- 
ing subsided), or perforation, with formation of abscess in the adjacent 
parts. 

Tubercular deposit occasionally affects the vesiculae, chiefly in cases 
of extensive tuberculosis : it appears as " a thick yellow, cheesy, larda- 
ceous, fissured, purulent layer," which replaces the mucous membrane, 
and causes thickening of the superficial layer of their coats. It never 
occurs before puberty. Scarce anything is known respecting cancer of 
these parts except that they only suffer secondarily from extension of 
adjacent disease. 



ABNORMAL CONDITIONS OF THE PROSTATE GLAND. 

The prostate is imperfectly developed when the organs of generation 
are so. Its size is diminished in some cases, when the testes are atro- 
phied ; it is then rather consolidated in texture. In other cases it un- 
dergoes what has been termed eccentric atrophy ; by which is meant 
the dilatation of its cavities, with thinning of its walls, in consequence 
f of the increase in size of calculous concretions in its follicles." " Cases 
sometimes occur, in which the whole of one lobe, or even the entire 
organ, is converted into a thin fibrous capsule, the proper substance of 
the gland being almost wasted." 

Hypertrophy of the prostate is extremely common, and to some ex- 
tent may be regarded as an occurrence natural in old age. It comes on 
quite imperceptibly, as one of those changes whose existence is unknown 
till their secondary effects begin to be produced. The enlargement may 
take place in all the dimensions of the gland, so that it expands later- 
ally, downwards, and upwards. Most often, one lateral lobe is enlarged 
more than the other, which occasions a deviation of the urethra to the 
other side. It said that the left is the one most commonly affected, 
and that it also frequently projects more than the right towards the 



600 



ABNOKMAL CONDITIONS OF THE 



cavity of the bladder. This, however, is by no means an invariable rule. 
The middle lobe is commonly enlarged more or less when the lateral 
lobes are so, but may attain a great size without any corresponding hy- 

Fig. 315. 




Lobulated hypertrophy of prostate. 



pertrophy of the lateral. It forms a kind of pyramidal elevation, pro- 
jecting into the cavity of the bladder, and causing the urethral orifice to 



Fig. 316. 



Fig. 317. 




Hypertrophy of middle lobe. 



be raised, and in some measure blocked up. The enlarged middle lobe 
has been found of the size of a small orange ; more often, it does not ex- 



PROSTATE GLAND. 



601 



ceed that of a walnut ; its surface may be smooth or nodulated. The 
hypertrophy of this part, when considerable, has the effect of throwing 
the neck of the bladder forward, and increasing the depth of its lower 
region so that calculi may lodge behind and below the. prostate in its 
cavity. The canal of the urethra becomes lengthened in its prostatic 

Fig. 318. 




Irregular hypertrophy of third lobe. 

portion; sometimes divided into two channels by the projection of the 
middle lobe ; or is tortuous from being curved to one side ; or, in con- 
sequence of its vesical orifice being raised, describes a curve whose con- 
vexity is downward. Its pressure on the rectum causes flattening o£ 
that channel, and more or less uneasiness in it, and may, perhaps, 
occasion haemorrhoids, or prolapsus ani ; in the same way it irritates 
the vesiculse seminales, and induces thickening of their walls ; pains felt 
in the parts to which the sacral nerves are distributed may be dependent 
on direct contact of these nerves with the enlarged gland, or on a re- 
flected stimulus conveyed to their place of origin along the compressed 
vesical and hemorrhoidal filaments ; the most important result, how- 
ever, of the enlargement, is the obstacle which it causes to the complete 
evacuation of the bladder. This depends partly on the narrowing of the 
urethra, and partly on the circumstance that a certain quantity of urine 
is always contained in the lower part of the bladder, below the elevated 
orifice of the urethra. In some cases the urethra, instead of being nar- 
rowed by compression, so as to appear like a slit on a transverse section, 
is considerably dilated, so that the prostatic sinus may contain two or 
three ounces of urine. An enlarged prostate is often indurated, so that 
by older writers it has been called scirrhous. The retained urine de- 
composing, causes irritation and inflammation of the bladder, with all 
its results, such as we have already described. Moreover, as Mr. 



602 



ABNOKMAL CONDITIONS OF THE 



Coulson describes it, the enlarged middle lobe becoming broader, and 
raising up a transverse fold of mucous membrane, which passes off on 
each side to the lateral lobes, constitutes a kind of valve, which is pushed 
before the urine in every attempt that is made to void it, " and closes up 
the opening till the cavity of the bladder is very much distended ; then 
the anterior part of the bladder being pushed forward, and the tumor 
being drawn back in consequence of the membrane of the posterior part 
of the bladder being put on the stretch, the valve is open, so that a 
certain quantity of water is allowed to escape, but the bladder is not 
completely emptied." 

Acute inflammation may attack the prostate, commonly as the result 
of suppressed gonorrhoeal discharge ; it may go on to suppuration, or 
cause chronic enlargement, or an irritable condition of the gland, with 
increase of its secretion. When abscess occurs, there may be one or 

Fig. 319. 




Abscess of prostate. 

several ; a single one, large enough to contain half a pint of matter, or 
small and numerous foci, so that the gland appears riddled with holes. 
The abscess may open into the bladder, into the prostatic sinus of the 
urethra, into the rectum, or, externally, into the perineum. 

Ulceration of the prostate scarcely occurs, except in some cases of 
chronic hypertrophy. It occasions severe suffering, and the admixture 
of blood with the urine. 

Tubercle is not of frequent occurrence in the prostate ; it is generally 
coexistent with tuberculosis of other parts of the generative apparatus 
and of the lungs. It may form a single large mass, or numerous small 
separate ones. As the tubercles soften and disintegrate, they give rise 
to abscesses, which pursue the same course as those of inflammatory 
origin. 

Cancer is rare in the prostate; five cases of it only were met with by 
M. Tanchou among 8,289. The scirrhous species is scarce ever observed. 
Encephaloid, either primary or extending from the bladder, is almost the 
only form that occurs. It causes considerable enlargement of the gland, 
and may also perforate the mucous membrane of the bladder, and vege- 
tate in its cavity, filling it up so completely as to give rise to the idea of 
the viscus being distended with urine. The disease occurred in a patient 
of Mr. Stafford's, at the age of five years, and in one of Mr. Solly's, 
at three. 

Fibrous tumors, as Rokitansky and Mr. Adams testify, are frequently 



PROSTATE GLAND. 



603 



Fig. 320. 




A cyst of the prostate gland. 



found in the prostate. They vary in size from that of a pea to that of 
a nut ; cause distinct hypertrophy of the 
gland, to whose tissue, however, they are, at 
least in some cases, but loosely attached. 

Cysts are, in extremely rare cases, formed 
in the prostate, as Mr. Adams thinks, by clo- 
sure of the outlets and dilatation of the cavi- 
ties of follicles. The fold of mucous membrane 
constituting the uvula vesicle is sometimes so 
raised up by the increase of the subjacent 
tissue, or by that of the third lobe of the 
prostate, that it obstructs the free exit of 
urine; this is not to be confounded with simple 
enlargement of the middle lobe. 

Concretions, in greater or less number, are 
of almost constant occurrence in the pros- 
tatic cavities ; they often may be seen, on 
making a section of the gland, as reddish, 
yellow grains. The larger, fully formed ones 
have a beautiful laminated structure, and resemble a good deal a section 
of a lithic acid calculus. Their form varies very much ; in the smaller 
it approaches the oval or circular, in the larger it is more polygonal or 
triangular. They are not unfrequently pale or colorless. They origi- 
nate in large oval vesicles, formed of a well-marked homogeneous en- 
velop. These appear to increase in size, while concentric laminae are 
formed in their interior, whose interspaces are occupied by a finely- 
mottled deep-yellow or red matter. A central cavity is almost always 
left within the last- formed laminae. Deposition of organic matter may 
take place, in some cases, exterior to the original envelop, but in most 
it appears to be within. Concretions of older 
date seem to lose the beautiful definiteness of 
their structure, and tend to disintegrate. The 
contents of these semi-organized formations 
appear to be earthy matter (phosphate, with a 
little carbonate of lime), tinged by the ordinary 
yellow pigment which is so often derived from 
the blood. We do not think they are deve- 
loped from the ordinary epithelial particles 
of the gland, but that the original vesicles are 
cells of a particular kind, which are produced 
from organic exudation upon the mucous sur- 
face, and fill themselves, as their growth pro- 
ceeds, with successive deposits of materials, 

which are probably poured out when the gland is the seat of vascular 
excitement. It is most probable that, in ordinarily healthy states, these 
concretions undergo solution at an early period of their existence, yield- 
ing up their contents to form part of the secretion of the gland. But, 
if this does not occur, and they go on increasing in size, they become 
the nuclei of, or are developed into, prostatic calculi. These are not 
unfrequently very numerous ; as many as fifty or sixty have been found 



Fig. 321. 




Prostatic calculi. 



604 



ABNORMAL CONDITIONS OF THE PENIS. 



in an atrophied dilated prostate, which has, in consequence, when ex- 
amined per rectum, given the sensation of a bag of marbles. The calculi 
sometimes cohere together, and form a large mass, projecting into the 
membranous portion of the urethra, which becomes in consequence much 
dilated. A remarkable case of this kind has been recorded by Dr. 

Fig. 322. 




Prostatic concretions. 



Herbert Barker, 1 in which 29 calculi, weighing together 1,681 grains, 
were cemented together so as to form a single concretion, which was 
nearly five inches long, and of an elongated pyriform shape. The sur- 
faces of these calculi are faceted from mutual pressure ; they are of a 
whitish or reddish color, of porcellaneous lustre and hardness, with a 
radiated, laminated, or compact structure. Lassaigne's analysis gives 
the following as their composition : basic-phosphate of lime 84.5, car- 
bonate of lime 0.5, animal matter 15. The smaller calculi often escape 
into the bladder through the dilated prostatic ducts ; if they remain 
there, they excite irritation of the mucous membrane and deposition of 
phosphates upon their own surface. A coating of lithic acid has some- 
times been formed on a large calculus remaining in the prostatic portion 
of the urethra. 



ABNORMAL CONDITIONS OF THE PENIS. 

The penis is very imperfectly developed in some cases of normal 
condition of the other sexual organs, as well as when they are themselves 
imperfect. We have seen it extremely short and fissured in its whole 
upper surface, in a case of ever no vesicse. When it is very small, fissured 
below, and destitute of prepuce, and when at the same time the testes 
remain in the abdomen, and the scrotum is cleft, there results a con- 
siderable resemblance to the female conformation; or if the penis is less 
atrophied, a pseudo-hermaphroditism. Atrophy of the penis, accompa- 

1 Transact, of Prov. Med. and Surg. Association, vol. iii. 1846. 



ABNORMAL CONDITIONS OF THE PENIS. 605 

nied by obliteration of the cavernous textures, occurs, according to 
Rokitansky, together with atrophy of the testicles. 

Hyperemia of the penis, being in the exercise of its function a natural 
occurrence, scarcely ever seems to become morbid. It has, however, 
occasionally happened, during coition, that the erectile texture has given 
way in some part — probably from the rupture of some of the trabeculse 
containing the small arteries. The consequence of this is, that the organ 
appears broke, and cannot assume the erect condition beyond the part 
injured. Contusions, which occasion bleeding from the urethra, indi- 
cating that laceration has occurred, are sometimes the cause of severe 
strictures ; in some of these cases, inflammation may have been set up, 
resulting in the effusion of coagulable lymph; in others, the deposited 
fibrin of effused blood has furnished the induration-matter. " Inflam- 
mation of the cutaneous investment of the glans (balanitis), which is 
generally complicated with inflammation of the internal lamina of the 
foreskin, gives rise to excoriation, exudation of coagulable lymph, adhe- 
sion of the prepuce to the glans, suppuration, and ulceration; when 
chronic, it induces exuberant formation of epidermis; and if the deeper 
parts of the parenchyma of the glans are involved, obliteration, cartila- 
ginous induration, and atrophy, follow." 

The vesicles of herpes sometimes form on the prepuce, on its mucous 
or cutaneous lamina. These are not to be confounded with the specific 
ulcerations, termed chancres, which may form on the internal surface of 
the prepuce, the frsenum, and near the meatus within the urethra, as 
well as upon the glans, which is their usual site. We give Mr. Druitt's 
terse description of the appearance of the various forms of chancre, pre- 
mising that he has selected the principal types: — 

The Hunter ian chancre is nearly circular, deep and excavated ; the 
base and edges are hard as cartilage, but the hardness is circumscribed ; 
there is little pain or inflammation; its color is 
livid or tawny. It may occur upon the common 
integument, the glans or body of the penis; in 
the latter situation it is never so hard and exca- 
vated as it is on the glans. 

" The non -indurated chancre is more frequently 
found on the inner surface of the prepuce." It 
appears as a foul yellowish or tawny sore, at- 
tended with slight redness, and swelling and 
spreading circularly. It subsequently throws out 
indolent fungous granulations, unless it be situated 
on the glans, where they do not form. A vertical sore on a com- 

Phaqedenic chancres are of irregular shape, mon J 5 "!* The characters 

, t . i t t . , ° . /. are chiefly those of the Hun- 

their edges ragged or undermined, their surface terian chancre _ After Acton . 
yellow and dotted with red streaks; their dis- 
charge is thin, profuse, and sanious. The surrounding margin of skin 
usually looks puffy and oedematous ; but sometimes it is firm, and of a 
vivid red. The cicatrices left by chancres which have healed, are whitish, 
more or less hard, striated, and depressed. 

Psoriasis of the prepuce produces a red, thickened, and fissured condi- 




606 



ABNORMAL CONDITIONS OF THE PENIS, 



tion of the part, which bleeds, whenever an attempt is made to draw it 
back ; and in consequence phimosis is apt to occur. 



Fig. 324. 



Fig. 325. 





Phymosis. 



Paraphymosis. 



Fig. 326. 



Paraphymosis is the opposite condition, in which a tight prepuce 
having been drawn back, constricts the neck of the glans, from having 
itself become thickened, and thus occasions a distended state of the glans, 
and even mortification, unless the stricture be removed. Phymosis is 
apt to give rise to attacks of balanitis, from the accumulation of the 
secretions of the coronal follicles. 

Warty vegetations belonging to the class of epithelial tumors some- 
times form on the glans, or on the inside of the prepuce; they are 
commonly the result of repeated inflammatory 
excitement, and are capable of being cured ef- 
fectually by removal. 

Cancer may affect any part of the penis, but 
is most frequent on the glans and prepuce. 
Rokitansky says, that it chiefly assumes the 
encephaloid form ; but we think the epithelial 
is more often met with, at least in the site 
which has been mentioned as its favorite. Dr. 
Walshe speaks of scirrhus as the species which 
usually affects the penis, though it may subse- 
quently give rise to encephaloid vegetations. 
He states that the disease may originate as a 
warty excrescence, or as a pimple, which dis- 
charges an excoriating fluid, scabs, and breaks 
out afresh, while induration, followed by ulcera- 
tion, advances at its base ; or it may infiltrate the glans, so as to con- 
vert that part into an indurated mass ; or venereal ulcers may take on 
cancerous action, and fungate as primary cancer. Secondary cancers, 
except in the adjacent glands, are not of common occurrence. Phymosis, 
and the irritation attending upon it, seem to act as exciting causes ; 
advanced age as a predisposing. 




Warts on Penis. 



THE PATHOLOGICAL ANATOMY OF THE 
FEMALE ORGANS OF GENERATION. 



CHAPTER XXXVII. 

THE EXTERNAL ORGANS OF GENERATION. 

The various tissues entering into the composition of the external 
organs of generation of the female are liable to numerous affections, dif- 
fering according to the immediate seat of the lesion. In the pudenda, 
•which we shall notice first, we have to deal with the cutaneous covering, 
the mucous lining, the loose, intervening cellular tissue, and the seba- 
ceous and mucous follicles. The relation of the parts as the organs of 
copulation, is one, that, in addition to the pathological questions they 
give rise to, often has a most important bearing upon medico-legal points 
of vital interest, which it is necessary for the medical man to understand 
well, as numerous cases are on record of a misappreciation of the cir- 
cumstances having led to very mischievous results. In the labia, sugil- 
lations are frequently met with as a result of external violence, or after 
parturition ; the effusion from a violent injury may give rise to very 
considerable tumefaction, which must not be confounded with varicose 
swellings. When the consequence of childbirth, it generally affects the 
left labium, 1 and occurs more frequently in primiparse than multipara. 
The swelling in either case has been known to attain the size of a fist, 
or a child's head. It presents a tense, smooth surface, with a livid color. 
Varicose veins of the labia may also acquire a very considerable size ; 
but the slow increase of the tumor, and the vermicular character of its 
contents, will determine the diagnosis. Varicose swellings, too, occur 
during the course of pregnancy, and, though sometimes very considera- 
ble, do not generally cause any impediment to parturition, as they are 
external to the vulva. Cases, however, are recorded of their sudden 
laceration during parturition, and of a consequent fatal issue. The he- 
morrhagic tumor disappears spontaneously, or in consequence of treat- 
ment, but exceptionally the swelling persists, probably becoming encysted, 
and may then be borne for an indefinite period. A case is related by 
Mauriceau, 2 in which a tumor, originating in this way, existed for twenty- 

1 Kilian, die Geburtslehre, &c, vol. ii. p. 517. 1840. Frankfurt. 

2 Observations sur la Grossesse et 1' Accouchement des Femmes. Paris, 1695. Obs. 29. 



608 THE EXTERNAL ORGANS OF GENERATION. 

five years. Inflammatory affections of the labia may arise from internal 
and external causes, and exhibit the various forms of inflammation met 
with in other superficial textures. Eczematous and aphthous inflamma- 
tion, as a result of derangement of the digestive organs, of pregnancy, 
of a want of cleanliness, or of sexual over-indulgence, are common. 
Eczema is characterized by the appearance of a vesicular eruption scat- 
tered over the inner or outer surface of the labia. The vesicles break 
and scab, and they are the source of much of the pruritus to which 
females are subject. 

The loose cellular tissue, occupying the interval between the external 
and internal lamina, especially favors cedematous swelling, and, when 
the inflammation bears a phlegmonous character, extensive sloughs 
form. Instances of this in early life are recorded by Mr. Kinderwood, 1 
who witnessed an epidemic at Manchester, marked by great fatality. 

The mucous crypts, especially the aggregation lying on each side of 
the vestibulum, and termed by Bartholinus the female prostate, are liable 
to inflammation from catarrhal, herpetic, syphilitic, or other causes, re- 
sulting in chronic ulceration or tedious discharges. Even young child- 
ren are frequently liable to simple or benignant inflammatory affec- 
tions of these parts, giving rise to much irritation and muco-purulent 
secretion — a circumstance with which it is necessary to be acquainted, 
as popular prejudice is only too prone to attribute it to contagion. 

The syphilitic taint gives rise to warty excrescences of the dermoid 
tissues, which may affect the labia and the introitus vaginae. They con- 
sist of groups of small pedunculated tumors, aggregated together in such 
a manner as to produce a sort of mushroom appearance. These warts 
are not identical with, though they resemble, the tubercule muceux of 
French writers on syphilis. Mr. Safford Lee describes these as round, 
flattened tubercles, raised above the surrounding tissues, sometimes be- 
coming elongated, of a reddish-blue color, and frequently ulcerated on 
their surface, producing a moisture of the parts. 2 

Encysted tumors of slow growth affect the labia, and are probably 
due to an obstruction in the first instance, and subsequent distension of 
one or more of the follicular structures. They consist of a membranous 
envelop, containing a transparent, glairy fluid ; and only prove a source 
of inconvenience after they have attained a large size. Other tumors 
are described as occurring in the pudenda, independently of the hyper- 
trophy resulting from chronic inflammation. Sir Charles Clarke has 
described a variety under the designation of the oozing tumor of the 
labium, which is chiefly characterized by a profuse watery discharge, 
corresponding in appearance with that from the cauliflower excrescence. 
It is but slightly elevated above the skin, and has an irregularly nodu-l 
lated surface. It occurs in persons advanced in life, endowed with 
general obesity, and in whom the labia are enlarged. Erectile andj 
scirrhoid tumors are also met with in this part of the system. A re- 
markable specimen of the latter is preserved in the Royal College of | 
Surgeons of England (No. 2715), which was successfully removed by 

1 Medico-Chirurg. Trans, vol. vii. p. 84. 

2 Safford Lee on Tumors of the Uterus, &c. p. 254. London, 1847. 



THE EXTERNAL ORGANS OF GENERATION. 609 

operation. It weighed upwards of eleven pounds, and is six inches in 
diameter. It is covered with healthy skin, and consists of a pale and 
compact, but soft and elastic, tissue, traversed in some parts by irregu- 
lar, shining fibres, and in others having several small oval cavities in it. 
The patient was thirty years of age, and the tumor had been growing 
for many years. Under the head of hypertrophy, we must also allude 
to the liability of the labia being affected by elephantiasis. The nymphae 
or labia minora are often abnormally enlarged, and frequently the seat 
of chronic inflammation, and consequent induration. In new-born infants 
they normally project beyond the labia majora, and, in some wild tribes, 
the custom exists of inducing their elongation by artificial means ; this 
is said to be the case among the Bushmen and the Kamschatdales. 
Among the Arabs and Copts circumcision of females prevails, which 
consists in removing a portion of the elongated nymphse. The enlarge- 
ment of the nymphae has been set down to an abuse of sexual indulg- 
ence ; but this is, probably, as incorrect as the same statement has been 
shown to be with regard to hypertrophy of the clitoris. This rudiment- 
ary penis excites no attention, unless enlarged much beyond its normal 
proportions. It is capable of assuming the most extravagant size. 
Some of the cases of hermaphrodism that are on record may be explained 
by a reference to congenital hypertrophy of the clitoris. The largest 
specimen that we have met with is preserved in the Museum of the Uni- 
versity of Bonn. It is fourteen inches in circumference, and weighs 
eight pounds. Mr. Safford Lee quotes several instances of similar 
hypertrophic enlargement. Parent Duchatelet met with enlarged clitoris 
in only three cases of 6,000 registered prostitutes in Paris. Dr. ,Ash- 
well, in his remarks on the subject, expresses his concurrence with the 
last observer as to there being no necessary connection between an 
habitual sexual indulgence and the permanent increase of the clitoris. 
He adds, that he has often been struck with the integrity of the external 
genitals in prostitutes, while the uterus and ovaries have been bound in 
all directions by bands of false membrane. The warty growths, already 
spoken of, also affect the clitoris, and it is occasionally the seat of 
malignant degeneration, where the parts of generation are generally 
involved. 

In the Pathological Society's Report for 1847-48, Mr. Brooke has 
recorded a case of malignant disease of the clitoris, which caused an 
excrescence of the size of a nut, attached by a pedicle, and which, 
having ulcerated and involved one of the nymphae, was successfully 
removed by an operation. In this case it does not appear that the 
system at large was at all affected. 

We allude to the urethra at present, only to speak of certain affec- 
tions of the orifice which opens beneath the clitoris, into the vestibular 
portion of the vagina. The very large crypts and sebaceous follicles 
surrounding this sensitive point, are the frequent seat of blennorrhaic 
and other forms of inflammatory action. The mucous membrane of the 
part is liable to an hypertrophic development, giving rise to small vas- 
cular, generally pediculated tumors. They are exquisitely sensitive 
during life, and the surface being easily abraded by contact, they fre- 
quently exude small quantities of blood, or they are the cause of painful 
39 



610 THE EXTERNAL ORGANS OF GENERATION. 

micturition and protracted leucorrhoea. The mucous membrane sur- 
rounding the orifice of the urethra is very apt to become hypertrophied ; 
the affection is described, by Sir C. M. Clarke, as consisting of an 
inflammatory hardening and thickening of the cellular structure, with 
an increase in the erectile tissue of the part. 

The valvular fold of membrane which protects the virginal vagina, 
the hymen, which is commonly ruptured when coition is first completely 
effected, has been a subject of much discussion by medical jurists, as its 
absence has been regarded as an unequivocal sign of defloration, or its 
presence as a proof of the unimpaired virginity of the individual. Neither 
position is absolutely correct ; for the best authorities are agreed, that, 
on the one hand, it may be destroyed by ulcerative absorption ; or, on 
the other, that it may persist, not only after coition, but even after par- 
turition. The latter fact is corroborated by the testimony of Merriman, 
Nagele', Ramsbotham, and others. Other deviations from the normal 
state of the hymen are, the cribriform perforations that it exhibits ; or 
it surrounds the entire introitus vaginse, leaving a central circular ori- 
fice, or it entirely excludes the passage. The latter circumstance is 
not likely to be discovered, as other atresise of the external orifices are 
early in life. With the approach of puberty it will induce much incon- 
venience from the mechanical retention of the menstrual discharge, and, 
unless discovered and rectified, will be the source of serious disturbance. 
The hymen is sometimes found much indurated, and of a cartilaginous 
consistency, and even osseous deposits have been met with in it. The 
hymen, after it has been ruptured, is partially, if not entirely, absorbed. 
The carunculae myrtiformes, which have been generally looked upon as 
the remains of the hymen, are now regarded by many authorities as 
normal formations that are not associated with lesion of the hymen. 



THE VAGINA. 

The vagina presents very considerable varieties of conformation and 
size within the normal limits of health, differences depending upon the 
age of the individual and the effects of cohabitation or childbirth, or 
the absence of these influences. A congenital closure of the passage 
may, independently of an imperforate hymen, or adhesion of the labia, 
convert the vagina into a cul-de-sac, a lesion which can scarcely be 
attributed to anything but intra-uterine inflammation, if the uterus be 
present. A remarkable instance, which appears to have been an arrest 
of development, is detailed by Dr. Boyd, J where, in a female, aet. 72, 
who had been married, though necessarily without issue, the vagina 
terminated in a cul-de-sac about half an inch deep, beneath the orifice 
of the urethra. There was no vestige of a uterus, nor any Fallopian 
tubes ; the right ovary was natural, and attached by a loose ligament 
to the bladder ; the left ovary was abnormal, but similarly connected 
with the bladder. A multiplication of parts is, perhaps, more fre- 
quently met with, and is produced by the formation of a septum, which 

1 Medico-Chir. Trans., vol. xxiv. p. 187. 



THE EXTERNAL ORGANS OF GENERATION. 611 

is more or less complete ; it may extend through the entire length of 
the vagina, or only partially divide it. A remarkable specimen of this 
malformation was exhibited by Mr. Birkett before the Pathological So- 
ciety ; l the vagina of a married woman, who had never borne children, 
and had died of pneumonia and pericarditis, was completely divided in 
the mesian line by a strong, dense, fibrous septum, extending from the 
external opening to the uterus ; thus two vaginas existed ; each vagina 
led to a distinct os uteri, both of which were small ; the neck of the 
uterus was rather longer than usual, the body smaller ; the uterus itself 
was nearly divided into two cavities by a septum in the mesian line. 

Occlusion, or stricture of the vagina, sometimes occurs as a result of 
external injury, or of cicatrization of ulcers. The rigidity or laxness 
of the walls varies much in different subjects, according to the general 
habit and the amount of secretion from the glandular apparatus sur- 
rounding the vagina. The great capability of the vagina for extension 
is best shown in parturition ; hence, it is not to be wondered at that 
prolonged uterine or vesical disease should induce a very lax state of 
the mucous membrane of the vagina, which, as it often does, becomes a 
source of extreme distress and inconvenience to the party affected. In 
old women, we often meet with this relaxed condition, which may amount 
to a complete prolapsus. The anterior wall is particularly prone to be 
thus affected. Dr. Golding Bird has recently 2 pointed out that this 
lesion gives rise to a fetid, phosphatic, and mucous state of the urine in 
elderly females, owing to an accumulation of the urine in the prolapsed 
bladder lying in a pouch of the anterior vaginal wall. He shows that 
it may be the source of great irritability of the bladder and incontinence 
of the urine, which is best relieved by frequent catheterism, so as en- 
tirely to empty the bladder. Dr. G. Bird compares the condition with 
that resulting in men from enlarged prostate. In prolapsus of the 
uterus, the mucous membrane of the vagina is necessarily dragged down 
with the descent of that organ. 

The vagina and the external organs are exposed to mechanical inju- 
ries of various kinds, and, in certain medico-legal questions, it requires 
care to determine their exact nature, as well as to avoid confounding 
the menstrual discharge with hemorrhage resulting from injury. Par- 
turition frequently gives rise to laceration and severe contusions of 
these parts. The inferior portion of the canal, either from unusual 
rigidity, or from want of proper care on the part of the attendant, is 
apt to give way when the labor-pains are at their climax; and the lesion 
may vary from a mere laceration of the fourchette to a rupture of the 
entire perineum, from the vagina to the anus. It necessarily happens 
that the perineum is perforated before the infant reaches the natural 
outlet, and that it passes through the adventitious opening without 
establishing a communication with the former. Laceration of the upper 
portions of the vagina also occur to a varying extent, in conjunction 
with, or independently of, rupture of the uterus. A small laceration is 
not necessarily fatal. Ross 3 reports the case of a woman who was twice 

1 Report, &c, 1847-48, p. 295. 2 Medical Times and Gazette, January 1, 1853. 

3 Dr. Francis H. Ramsbotham gives this and other illustrative instances in his Prin- 
ciples and Practice of Obstetric Medicine and Surgery. London, 1841, p. 603. 



612 THE EXTERNAL ORGANS OF GENERATION. 

the subject of an accident of the kind, and each time recovered. This 
result is out of the question, when, as occasionally happens, the child 
escapes into the peritoneal cavity. 

The mucous membrane of the vagina is very frequently the seat of 
inflammation; the commonest form is the catarrhal. In the first stage, 
the passage is reddened, heated, and dry; this is followed by the secre- 
tion of a white, creamy mucus ; or, if there be anything of a specific 
character, the discharge is more purulent or flaky. Whether simple or 
complicated, it often assumes a chronic character, and is then converted 
into a blennorrhcea, which, by the mere loss of fluid entailed upon the 
patient, often exerts a most debilitating effect. The secretion of the 
vagina in leucorrhoea has been recently shown by Dr. Tyler Smith, 1 to 
consist mainly of squamous epithelium and epithelial debris, though its 
essential characteristic, by which it is distinguished from the discharge 
derived from the cervix uteri, consists in its acid reaction, the interior 
of the cervix yielding an alkaline fluid. "It is to this alkali that the 
secretion within the cervix owes its viscidity and transparency, while 
the curdled appearance of the vaginal mucus is owing to the presence of 
the vaginal acid." As the acid of the vagina is sufficient to neutralize 
the alkaline secretion of the uterus, the fact of the latter being frequent 
and copious is masked; hence the discrepancy of the opinions of various 
authors on the subject of the source of leucorrhoea. The external sur- 
face of the os uteri, according to Dr. Tyler Smith, yields a secretion of 
the same character as the vagina itself. In both eczematous vesicles 
are frequently met with, which the same author regards as identical 
with the ovula Nabothi, which, by some have been interpreted as ob- 
structed follicles, but Dr. Tyler Smith asserts that they are often found 
in situations where mucous follicles cannot be detected. 

Rokitansky describes exudation, or croupy processes occurring in the 
vaginal mucous membrane primarily, but more frequently in conjunction 
with a similar disease of the uterus, in the shape of puerperal disease. 
-' Exudative processes," he observes, "with various products, occur more 
frequently in patches, or throughout the vagina, as secondary diseases, 
both as a result of puerperal affection of the uterus, as well as in conse- 
quence of an infection of the blood proceeding from other causes, or 
from a degeneration of the typhous and various exanthematic processes. 
They correspond to the condition of the blood and its products, and 
accordingly produce a solution of the mucous membrane and the sub- 
mucous layer, varying in shape and depth, and not unfrequently re- 
sembling gangrenous destruction. A loss of substance may ensue, and 
to this cause undoubtedly many cicatrices found in these parts are to be 
attributed." The secondary form of typhus occurring in the vagina, 
Rokitansky states, does not exhibit itself in the vagina in its genuine 
form, but is often found degenerated into croup and gangrene ; an ex- 
isting blennorrhcea, especially if of gonorrhoeal or syphilitic origin, 
exerting a powerful attraction upon it. 

A chronic thickening of the vaginal mucous membrane is occasionally 
met with ; the follicular, the syphilitic, and the carcinomatous ulcer, 

1 Medico-Chirurgical Trans , vol. xxxv. p. 377. 



THE EXTERNAL ORGAN'S OF GENERATION. 613 

also affect this part. Gangrene sometimes results from the effect of 
parturition, or the contusion caused by rough manipulation. The cica- 
trix that results from the healing of a slough is occasionally an impedi- 
ment at subsequent deliveries ; a puckering of the vaginal membrane, 
and consequent diminution of the passage, having taken place. 

The vagina is not often the seat of morbid growths. Polypi and en- 
cysted tumors are the varieties that most frequently affect this situation. 
The posterior part of the vagina is stated to be the ordinary seat of 
polypoid growths. 

An instance given by Mr. Curling, in the Reports of the Pathological 
Society, 1 forms an exception to the rule. Here the solid tumor which 
was removed from a woman, aged forty-five, grew from the upper part 
of the vagina, to w r hich it was attached by a broad peduncle, which 
commenced just behind the meatus of the urethra, and extended back- 
wards towards the uterus about two inches and a half. The structure 
of the polypi varies in character; they may be, as stated by Mr. S. Lee, 
fibrous-vesicular and cellulo-vascular — the fibrous being the least fre- 
quent. They vary equally in size, from a trifling projection to growths 
several pounds in weight. The encysted tumors of the vagina originate 
in an obstruction of the follicles with which the region abounds; they 
contain a glairy, transparent, greenish, or dirty-brown, albuminous fluid ; 
and, though the source of irritation and inconvenience, are not produc- 
tive of any danger: their correct diagnosis affords a speedy means of 
relief; but they have been repeatedly mistaken for totally different 
affections, such as prolapsus of the womb or the bladder, or for hernia. 

Specimens of carcinoma affecting the vagina are preserved in most 
museums of pathological anatomy ; they show that this part is commonly 
secondarily involved by an extension of the disease from the cervix 
uteri; "however, it may exist," to employ the words of Rokitansky, 
"though the latter is in a very undeveloped state, and even without it, in 
the shape of primary carcinoma of the vagina." The form in which it 
occurs is of the fibrous or encephaloid kind; malignant epithelial growths 
do not appear to affect the female organs of generation in the same 
manner as they occur in the male penis — a circumstance which may ap- 
pear remarkable, as both possess a great analogy in regard to the com- 
ponent structures and the secretions they give rise to. The smegma 
prseputii consists as essentially of epithelium as the vaginal discharges; 
and the perverted nutrition giving rise to epithelial cancer, may fairly 
be assumed to affect the secretory organs of the penis, and be regarded 
as an extravagant expression of the normal process. The fact, how- 
ever, is, that the mucous membrane of the vagina has not been shown 
to be obnoxious to this form of cancer. 

1 Vol. i.,p. 301, 1847-48. 



CHAPTER XXXVIII. 

THE INTERNAL ORGANS OF GENERATION. 

THE UTERUS. 

The uterus, unlike most other organs combining to form the human 
body, has a double existence; one of long- continued comparative qui- 
escence, and one of extreme, though brief, activity and development. 
The diseased processes aifecting it are mainly associated with, and the 
result of the changes that take place in it, during and immediately after 
pregnancy ; hence, its pathological relations scarcely come to the cogni- 
zance of the medical man until its proper functions have been called 
into action. Before considering its acquired abnormities, however, we 
must turn our attention to certain congenital anomalies presented by 
the organ, which have a bearing upon the future health of the adult 
individual. In a morphological and natural historical point of view, 
some of these malformations possess considerable interest; though we 
can only in so far advert to them as they regard the practitioner. 

We have already given an instance (page 610,) of an entire absence 
of the uterus — a malformation which need not affect the health of the 
individual. Rokitansky states that the occurrence is extremely rare, 
and that most of the cases in which the uterus appears to be absent 
may be resolved into a partial arrest of development only, and that, by 
careful examination, we may find behind the bladder one or two rudi- 
mentary bodies in the proper fold of the peritoneum which represent 
the uterus. An actual multiplication of the organ is equally rare; but 
it is not an uncommon thing to find a more or less complete attempt at 
the formation of a double cavity, which is manifestly the result of an 
arrest of development. The bilocular and horned uterus are the mal- 
formations alluded to ; in the former, a more or less perfect septum 
extends through the uterus in the mesian line; in the latter, the organ 
presents the character of the uterus exhibited by certain mammalia, as 
the sheep, and is divided into two lateral compartments by a fissure, 
extending vertically downwards from the fundus. This may be ex- 
plained upon the assumption of an imperfect union of the two rudiment- 
ary bodies from which the normal uterus is developed. Only one of 
these may arrive at maturity, and we then have to deal with a uterus 
consisting only of a single horn, or of one-half; there will then neces- 
sarily only be a single Fallopian tube. The uterus unicornis, as well 
as the uterus bilocularis and bicornis, are capable of becoming impreg- 



THE INTERNAL ORGANS OF GENERATION. 615 

nated; Rokitansky 1 details the particulars of an example of pregnancy 
in a rudimentary uterine horn, which terminated fatally by rupture and 
sanguineous effusion into the peritoneal cavity, in the third month. 
When the two halves coalesce, the division which constitutes the mal- 
formation may vary considerably in amount; only a slight depression 
may be visible at the fundus in one case, so that the organ scarcely de- 
viates from its normal condition; in another, the fissure extends so far 
down as to justify the appellation of double uterus, ordinarily bestowed 
upon the anomaly. An excellent instance of this is preserved in the 
Museum of St. George's Hospital (No. 104 of Dr. Lee's preparations). 
This preparation also illustrates what takes place after impregnation; 
while the ovum is received into one horn, which becomes duly developed 
with the growth of the foetus, the other only sympathizes with it so far 
as to form a deciduous membrane, and thus to prevent the occurrence 
of superfcetation, but otherwise undergoes but trifling alteration or in- 
crease. Though impregnation and parturition are not necessarily fatal, 
these malformations seriously endanger the life of the patient — owing, 
as Rokitansky observes, partly to the want of the necessary dimensions 
of the part that undertakes the functions of the entire organ, partly to 
the obstacle opposed to the uniform development of the impregnated 
uterine half, by the unimpregnated half. These circumstances favor 
laceration of the uterine parietes. Rokitansky also shows that the di- 
vergence of the cornua from the axis of the body causes an impediment 
in the act of parturition, while the expulsive power of the uterus is 
much reduced by the absence, in the case of the uterus bicornis, of a 
true fundus. 

Hypertrophy and atrophy of the uterus are, in part, normal at the 
periods of puberty and involution ; much tact is necessary to distinguish 
some of the morbid from the healthy conditions of the organ. The 
weight and dimensions of the adult uterus fluctuate in health considerably. 
Kilian 2 gives the following, as the result of his measurements: the entire 
length varies from twenty-four to twenty-six lines; the greatest breadth 
is eighteen lines ; the thickness, nine lines ; the cervix is from ten to 
twelve lines long ; its breadth, from six to eight ; its thickness, from five 
to six lines ; the length of the uterine cavity is twelve lines ; its breadth, 
nine lines ; the greatest thickness of the fundus, five lines ; of the sides, 
four lines ; and of the cervix, three lines. After one or more births, all 
these measurements increase from one-fifth to one quarter. The weight 
of the uterus varies from eight to twelve drachms, and may, after several 
pregnancies, amount to two ounces. With the aid of this table we shall 
be better able to determine whether we have to deal with a morbidly 
enlarged or diminished uterus. Either affection may involve the entire 
organ, or be manifested in a part only. An atrophic condition is pro- 
bably a frequent source of sterility; the organ, and especially the cervix, 
is small and anaemic, its tissue dense, and the ovaries present an equally 
undeveloped condition. After the climacteric period, the cervix often 
disappears entirely, and nothing but an indurated ring remains at the 
sumit of the vagina. 

1 Pathological Anatomy, vol. ii. p. 277. Syd. Soc. Ed. 

2 Die Geburtslehre, &c, von Dr. H. F. Kilian, Frankfurt, 1839, vol. i. p. 92. 



616 THE INTERNAL ORGANS OF GENERATION. 

Hypertrophy is more commonly met with as a morbid state, than 
atrophy ; partly, as an exagerated expression of the normal condition, 
at certain periods of life — partly, as the result of irritation, set up by 
other morbid processes. These may consist in tumors, occupying the 
substance, or filling the cavity of the uterus ; giving rise, eventually, 
to actual expulsive efforts, resembling labor-pains, or to blennorrhaic 
affections of the mucous surfaces. Mere consensual irritation, proceed- 
ing from other organs, may suffice to induce it. Thus, the Museum of 
St. George's Hospital contains a preparation of the internal female 
organs of generation (x. 7), in which the ovaries are seen to contain 
cysts, while the uterus, which otherwise is perfectly healthy, exhibits 
very marked hypertrophy. The cervix is liable to be hypertrophied by 
itself; the labia may form a single tumefied ring, or present two tumors, 
lying parallel to one another, and separated by a transverse fissure. The 
first form is more likely to occur in women who have not borne children, 
and the second in those who have. The anterior is more frequently 
enlarged than the posterior lip. 

The cavity of the uterus may be morbidly diminished in consequence 
of inflammatory affections of the surrounding textures, or by malposition 
or curvation, and may amount to complete obliteration. An instance 
of obliteration of the cavity of the uterus is preserved in the St. George's 
Hospital Museum (Dr. Lee's Preparations, No. 161), in which the cervix 
remained patulous. An instance of complete obliteration of the os uteri 
is recorded by Dr. A. T. Thomson, in the thirteenth volume of the 
Medico- Chirurgical Transactions, where, owing to this cause, in a female 
aged sixty-five, the uterus was found distended by eight quarts of brown 
fluid, slightly coagulated by heat. The patient had borne two children. 
We shall have occasion to see that the os and the cavity of the uterus 
are frequently plugged up by secretions, but this must not be confounded 
with actual adhesion of the parietes. Strictures are commonly met with 
at the external and internal orifices of the cervix ; they appear to be 
mainly due to inflammation of the mucous and submucous tissues of the 
parts. 

MALPOSITIONS OF THE UTERUS. 

No organ of the body is liable to so frequent, and so varied and ex- 
tensive changes of position, as the uterus ; all of which very materially 
affect the health of the individual and her prospects of maternity. 
There are two great classes of malpositions; those in which the uterus 
maintains its site but alters its axis — deflections from the normal posi- 
tion — and those in which it quits its nidus, and becomes altogether dis- 
placed, so that its relation to all the pelvic viscera is perverted. The 
deflections are known by the terms anteversion and retroversion, in 
which respectively the fundus uteri is tilted forwards, or pushed back- 
wards out of the ordinary axis. In either case, the abnormal position 
of the organ considerably interferes by its pressure with the functions 
of the adjoining organs, and especially the bladder and rectum, propor- 
tional to the amount of deviation. The term obliquity is applied to the 
lateral deviation from the axis which sometimes occurs, either as the 



THE INTEKNAL ORGANS OF GENERATION. 617 

effect of pregnancy, or of diseased conditions affecting one side only, 
and thus disturbing the balance necessary to the integrity of the viscus. 
Much difference of opinion has existed in reference to the question 
whether anteversion (or, as it is called by some, pronation) is a more 
frequent occurrence, or retroversion. Lisfranc asserts that anteversion 
is by far more common than retroversion ; Rokitansky positively states 
the latter to be the more ordinary occurrence. In these three forms of 
dislocation the different parts of the uterus maintain their proper mu- 
tual relations, but another variety exists in which the cervix and body 
form an angle (more or less acute) with one another. The deflection is 
almost invariably forwards; and may be congenital, as it is met with at 
early periods; and it is probably an impediment, though not a bar, to 
conception. Disordered menstruation accompanies most of the morbid 
conditions we have adverted to, but whether as a cause or as a compli- 
cation has not been determined. 

The second class of malpositions consists in a descent of the womb 
into the vagina, or in its extrusion beyond the labia; the term prolapsus 
has been, somewhat arbitrarily, applied to the lower degree, procidentia 
to the extreme form. In either case the axis of the womb must be 
altered, as well as its relations to the surrounding viscera. The pre- 
disposing cause is a lax state of the tissues generally, and more parti- 
cularly of the ligaments of the uterus and of the vagina, which may be 
the symptom of debilitated constitution, as in lymphatic individuals, or 
the result of repeated pregnancies. The immediate cause is very fre- 
quently an unusual bodily effort. The secondary effect upon the pro- 
lapsed organ is, that it is irritated, and that its surface ulcerates, or that 
it becomes the seat of congestion and hypertrophy, and that its exposed 
surface becomes indurated and horny. Prolapsus is most frequently 
met with after the middle period of life; instances of its occurrence 
before puberty are recorded by Dr. Ashwell, 1 and other authors. Dr. 
Ashwell's work also contains the history of three cases in which, during 
the whole period of pregnancy, the womb had lain partly or entirely 
external to the pudenda. In two of these the child was born while the 
entire uterus was beyond the vulva ; in one, it had occupied that posi- 
tion for several months, in the other for eight years previous to concep- 
tion. 

A very serious malposition, which comes on after parturition, spon- 
taneously, or as the result of undue manual interference in removing 
the after-birth, in an unusually distended or relaxed womb, is that known 
as inversion of the uterus. It consists in a greater or less descent of 
the fundus uteri into the cavity of the organ, and it may amount to a 
complete turning inside out. It is generally accompanied by very dan- 
gerous hemorrhage : if the organ is not at once replaced in its proper 
position, and the patient survives the immediate* shock, as sometimes 
happens, the uterus becomes reduced in size, and the inconvenience 
sustained may be comparatively trifling. Burns details a case in which 
an inverted uterus was borne for twenty years, menstruation continuing 
during the whole period. 

1 A Practical Treatise on the Diseases Peculiar to Women, p. 541. London, 1845. 



618 THE INTERNAL ORGANS OF GENERATION. 

Inversion is not, however, exclusively a sequel of parturition ; it also 
occurs as a result of the influence of fibrous polypi, growing from the 
inner surface of the fundus. An unimpregnated inverted uterus is 
preserved in the Museum of the Royal College of Surgeons of England 
(No. 2,654), showing the Fallopian tubes obliquely in the upper part of 
the vagina — the effect of a polypus growing from the fundus. Velpeau 
removed a polypus from a woman, who died soon after of peritonitis, 
and the uterus was found to have been completely inverted. The pre- 
sence of fibrous tumors in the substance of the uterus, or inclosed in 
the cavity, when complicating pregnancy, favors the occurrence of in- 
version, by disturbing the normal balance of the expulsive contractions. 
Some authors are inclined to attribute it to extreme shortness of the 
umbilical cord. Instances are recorded in which the entire inverted 
uterus has been removed by ligature, or by the knife ; in some cases 
inadvertently, owing to the tumor having been mistaken for a polypus, 
and of the patient's having entirely recovered. One of the latest cases 
is that given by Dr. J. Cooke. 1 

We have already had occasion to allude to the occurrence of rupture 
of the uterus, as a concomitant of pregnancy in the horned or bilocular 
malformation of the organ. The accident is also met with in the normal 
uterus. A trifling laceration at the os tincse occurs at every birth, and 
is, therefore, of no consequence ; and it appears that until the solution 
of continuity extends beyond the circular fibres of the cervix, no danger 
is to be apprehended. Above this point the rupture may prostrate the 
entire thickness of the parietes, so as to allow an escape of the foetus 
into the abdominal cavity ; or one layer only, either on the inner or outer 
surface, may give way. It has been shown by several observers that 
the peritoneal investment of the uterus may, during parturition, alone 
be lacerated, leaving the uterine substance entire. The direction of the 
rent is stated differently by authors. Rokitansky affirms that it is gene- 
rally vertical; Burns asserts it to be transverse, and Kilian maintains 
that it is commonly diagonal. It very rarely affects the fundus, but 
most frequently the posterior and inferior surface, which corresponds to 
the promontory, against which, in the act of parturition, the expulsive 
efforts propel the child with peculiar force. 

Rupture of the uterus occasionally takes place before parturition, as 
a result of external injury; it is said not to be necessarily fatal, nor as 
dangerous as might be supposed. Its occurrence during parturition is 
unfortunately not a mere pathological curiosity. According to the 
statistics of the Dublin accoucheurs, Drs. Cullen and Clarke, the average 
frequency is about one in five or six hundred births. The former met 
with 34 cases in 16,414 births, the latter had 4 cases in 2,484 parturient 
females. 

A remarkable circumstance is, that of the thirty-four cases that 
occurred in Dr. Collins's 2 practice twenty-three were male children, and 
he accounts for the fact by the circumstance that their heads are uni- 

1 On the Removal of the Uterus in Cases of Prolapsus and Inversion. London, 1836. 

2 Practical Treatise on Midwifery, &c. p, 244. 



MORBID GROWTHS. 



619 



forraly larger than those of female infants. The operation of turning 
is stated to give rise to the accident, and it also appears that primiparse 
offer a greater liability than multipara. 



MORBID GROWTHS. 

In order to avoid unnecessary repetition, -we shall postpone the con- 
sideration of the textural diseases of the uterus until after we have 
reviewed the morbid growths in the organ, in order that we may more 
conveniently connect the morbid states of the unimpregnated uterus 
with the diseased conditions occurring after parturition. 

The abnormal formations that most frequently present themselves in 
the uterus, are fibroid tumors; they occur imbedded in the texture of 
the organ, or protruding from its minor surface into the cavity, or from 
some part of the external surface. When projecting into the cavity of 

Fig. 327. 




Fibrous tumor projecting into the cavity of the uterus. — St. George's Museum, 128. 

the uterus they receive the name of fibrous polypi. While imbedded in 
the uterine tissue they form globular, white, glistening, dense tumors ; 
there may be only one, or they may be numerous. In preparation No. 
2,674, in the Royal College of Surgeons, we see a uterus, with from 
eight to nine large fibrous tumors in its walls, varying from one to four 
inches in diameter. In size they differ even more than in number ; they 
are seen in every gradation, from that of a pin's head to that of a melon. 
The preparation spoken of further on is an instance of the great deve- 
lopment they attain. Dr. Lee mentions one weighing fifty-four pounds, 
which contained several cysts filled with fluid. The fibrous tumor is 
surounded by a membrane which separates it from the uterine tissue, so 
that there is no very intimate union between the two structures. " The 
most usual position for these tumors," according to Mr. Lee's analysis 
of seventy-four cases, "is the submucous, viz: those projecting into the 
cavity of the womb, and the pedicles of these are generally situated 



620 MORBID GROWTHS. 

just below the openings of the Fallopian tubes. The next position in 
which they are most abundant is, the posterior wall and fundus of the 
uterus ; they are very rarely situated in the anterior wall, and still more 
rarely in the cervix uteri." Of the general truthfulness of these re- 
marks, every one may convince himself, by glancing through one of the 
metropolitan museums of pathological anatomy. It appears that the 

Fig. 328. 




A uterus, the upper half of which is enlarged by the growth of numerous fibrous tumors in its walls. One 
tumor, larger than the rest, projects into the dilated upper part of the cavity of the uterus, and completely 
fills it. Five others are shown by the section imbedded in the anterior wall, and many others project on the 
external surface of the uterus. The lower half of the uterus is healthy, but elongated. The walls of the 
portion occupied by the tumors are thick and laminated, like the walls of the uterus in pregnancy. — St. Bar- 
tholomew's Museum, xxxii. 16. 

nearer the original deposit takes place to the mucous surface of the 
uterus, the more a gradual extension of the entire growth into its cavity 
is likely to ensue. In this way we account for the gradual elongation 
of the pedicle, which after a time is the only connection between the 
tumor and its matrix ; it may then be removed with comparative facility 
by operative procedure. The pedicle is not, however, a necessary con- 
sequence of the arrival of the fibrous tumor at the external surfaces. 
In one of the largest specimens which has come under our notice, which 
is also remarkable as affecting the cervix (Royal College of Surgeons, 
No. 2,672) exclusively, the remainder of the uterus continuing normal, 
we find no attempt at the formation of a pedicle ; the tumor has evi- 
dently formed in the substance of the posterior part of the cervix, and 
in its growth has separated the uterine tissue, which is still spread out 
over the upper part of the tumor, as if embracing it. The tumor, in 
this case, is twelve inches long, by five inches thick, and presents the 
ordinary structure of fibrous tumors. The fibrous tumors found almost 
free in the abdominal cavity, or, at least, only attached to the uterus by 
cellular adhesions, probably have the same origin as the growths we 
have just considered; having been developed in the first instance under 
the peritoneal investment of the uterus, they have subsequently become 



MORBID GROWTHS. 621 

detached. This does not preclude the possibility of their being formed 
primarily, at the points where they are found. 

The intimate structure of fibroid tumors varies in some respects ; to 
the naked eye it exhibits, at times, a concentric disposition of fibres ; 
but more commonly, an irregular wavy appearance, without any uni- 
formity of arrangement, presents itself; and it is more particularly in this 
case that cavities containing blood, a dark-colored gelatinous fluid, or a 
clear serum, are formed, which give the tumor, on section, a resemblance 
to the sero-cystic disease of the testis or mamma. Occasionally, the 
fibrous tumor presents a tabulated conformation. The microscopic ap- 
pearances of the fibroid tumors of the uterus are not in accordance with 
what we should expect to find in a true fibrous structure. The micro- 
scope, in fact, demonstrates that they belong to an altogether different 
class of growths ; the fibrous appearance is scarcely perceptible under 
the microscope, which displays elongated nuclei, imbedded in an amor- 
phous stroma. It appears to us, that, from the analogy they present to 
the genuine uterine tissue, in the unimpregnated state, we should rather 
class them with homologous than heterologous productions ; that they 
should be regarded rather in a relation to the womb analogous to that of 
exostosis to the matrix it springs from, than of a character totally at 
variance with that of their nidus. 1 

The amount of blood supplied to fibrous tumors, varies. The majority 
are but scantily provided with vessels. Some, when injected, only ex- 
hibit one or two larger vessels traversing the substance of the mass; 
others exhibit considerable and uniform capillary injection. The he- 
morrhage to which fibroid growths of the uterus may give rise, is not owing 
to a laceration of these vessels, but to the irritation and congestion they 
induce in the superincumbent mucous membrane, which, from the same 
cause, may ulcerate and slough. When complicating pregnancy, they 
induce hemorrhage, by preventing the normal development of the organ; 
hence, they are very apt to give rise to miscarriages. Fortunately for 
the individuals, they are often a cause of barrenness. 

Not only the continued growth of these tumors, but also the occasional 
tendency to secondary changes occurring in them, manifest a greater 
vitality than some authors have ascribed to them. Thus, we find abscesses 
in the very centre of fibroid growths ; or they may contain encysted 
melanotic tumors, as in the case of two preparations (Nos. 181 and 122) 
in the Museum of St. George's Hospital. A species of ossification or 
calcification occurs in these growths, analogous to the process of the 
same kind met with in other morbid products; the production of true 
cartilage, and the subsequent conversion into ossific matter, is at least 
doubtful, and not to be credited until we receive positive microscopic 
evidence to that effect. The calcification sometimes commences super- 

1 Since the above was written, a corroboration of the view expressed has been published 
in the Report of the Pathological Society for 1853, p. 219. Dr. Bristowe, in an elaborate 
paper on the subject of fibrous tumors of the uterus, concludes, from his examinations of 
them in the impregnated and unimpregnated conditions, that all so-called fibrous tumors 
of the uterus, at least in their earlier stages, before degeneration has taken place in them, 
are essentially muscular tumors; not simply fibrous tumors with a greater or less quantity 
of muscular fibre mixed up with them, but developments of true and undoubted muscular 
tissue. 



622 POLYPI AND POLYPOID GROWTHS. 

ficially, at others, in the centre ; the process seems to promote the spon- 
taneous expulsion of the tumors from the uterus. When this occurs, 
the proper texture of the latter takes on similar action, as if a foetus were 
contained in its cavity, and it becomes hypertrophied. This is not the 
case as long as the tumors occupy the tissue of the uterine parietes ; here 
the pressure of the tumor rather inclines to produce atrophy; a remark- 
able example of this is spoken of by Dr. Lee, 1 in which, at least, in 
connection with a fibrous tumor at the fundus, the uterus had become 
so much atrophied as to resemble a mere bladder. Complete ossification 
may, however, take place, and the tumor be borne for an indefinite 
period, as in the case of the old lady mentioned by Mr. Arnott, 2 who, 
having died at the age of seventy-two, from the effects of a fall, was 
found to have a tumor weighing five pounds, and as hard as marble, in 
the uterine parietes, which had become converted into a mere membrane. 
The tumor had been diagnosed as scirrhus, when she was at the age of 
forty. It was found, on analysis, to contain nearly two-thirds of phos- 
phate of lime. 

Fibrous tumors have not been observed before puberty. Dr. Lee 
agrees with the statement made by Bayle, that they are most frequent 
in virgins, and that they exist in twenty out of a hundred middle-aged 
women. 

POLYPI AND POLYPOID GROWTHS. 

The growths which we shall next consider, though often confounded 
w r ith fibroid formations under the name of polypi, are essentially distinct 
from them. These formations are soft and succulent, and project into 
the cavity of the uterus, or depend into the vagina; they are attached 
by a pedicle of greater or less width to the surface from which they 
spring, while they are invested by the mucous membrane of the part. 
They are essentially a morbid condition of the surface structures, the 
mucous membrane, the follicles, or sebaceous crypts of the different parts 
of the uterus. According to their predominant character, they have 
been termed by different authors — vesicular, mucous, cellulo-vascular, 
or channelled polypi, or polypi of the Nabothian glands. The last have 
nothing in common with an ordinary polypus ; and, as Dr. Tyler Smith 
has shown, can only be regarded as a form of vesicular disease, affecting 
the cervix uteri. They are transparent cysts, one or more in number, 
and varying in size from a pin's head to a walnut, seated upon the cervix. 
They are generally sessile, but may become elongated, and thus acquire 
a pedicle. The mucous polypus is a pyriform projection from the inte- 
rior of the uterine surface, identical in structure with the villi of the 
uterus, and hence, to be regarded as hypertrophy of this tissue. The 
cellulo-vascular polypus is described as a small red tumor, lying between 
the os uteri, and very much resembling the excrescences of the orifice 
of the urethra. These growths are very liable to give rise to hemorrhage, 
and especially at the menstrual period put on the character of erectile 
tumors ; hence, they vary much in size, according to the quantity of blood 
they contain. 

1 Medico-Chirurgical Transactions, vol. xix. p. 94. 2 Ibid., vol. xxxiii. p. 109. 



CYSTS — TUBERCLE. 623 

The vesicular polypus is stated by Dr. Lee always to be situated at 
the fundus, under the lining membrane, which is very thin and vascular; 
he describes it as made up of a number of little round vesicles or cells, 
which contain a thin, transparent fluid ; the whole is supported by a thin 
fibrous tissue ; they are of a dirty white color, and sometimes present a 
slightly yellow tinge. The channelled polypus of the cervix is a rare 
form of the disease ; Dr. Oldham describes it as made up of several large 
channels, with occasional communications between them, and opening 
by large orifices on the free surface of the growth ; it does not appear 
as a compound of pendent enlarged cysts, clustering together, but as a 
solid single polypus, with numerous orifices on its surface. 

None of these soft growths can offer any impediment, as we see in the 
case of the fibroid tumors or polypi, to the act of parturition. When 
dormant, as they often are for a long period, they excite no symptoms ; 
but they become dangerous when the seat of vascular excitement, by 
the hemorrhage to which they give rise. It is satisfactory to know, that 
the operation by ligature or excision, if properly performed, is a sure 
means of arresting it-, a spontaneous cure has sometimes been effected 
by the constriction exerted upon the polypus, after it has passed the os 
uteri, by the circular fibres of the part. 



CYSTS. 

Cystic growths are extremely rare in the uterus. An instance of 
sero-cystic disease occurring here, is recorded in the first volume of the 
Pathological Society's Reports (p. 108). The tumor occupied the 
parietes of the organ, and presented a lobulated appearance ; and some 
lobes seemed composed of separate bodies of various form, contained in 
and connected with the parietes of cysts. A portion of a uterus is pre- 
served at the Museum of the Royal College of Surgeons of England 
(No. 2,657), in which, according to the catalogue, a very large encysted 
tumor had formed; the patient had been twice tapped and the cyst 
emptied ; it was supposed during life to be ovarian dropsy. The occur- 
rence of hydrometra, or a dropsical accumulation in the cavity of the 
uterus, is regarded by some authors as the result of a large hydatid 
forming in the latter ; but it is probable that it is rather owing to the 
perverted action of the lining membrane pouring out fluid, which accu- 
mulates, in consequence of the occlusion of the os tincae, and thus gradu- 
ally distends the womb. Dr. Ashwell describes, under the same head, 1 
the secretion and discharge of large quantities of limpid fluid, as a symp- 
tom of catarrh of the uterus ; but it appears, from one of the cases 
appended to the chapter, that it may also accompany fungoid disease 
of the organ. 

TUBERCLE. 

Tubercular deposit in the uterus, affects primarily the lining mem- 
brane, where it is deposited in the miliary form, or accumulated in 

1 On the Diseases of Women, p. 506. 



624 CANCER. 

masses, aggregated into nodules, or forming a cheesy layer over the 
entire surface; the uterine tissue becomes secondarily affected, and is 
then liable to become infiltrated with the morbid product. When the 
affection has been accompanied by a discharge, Dr. Reynaud has 
shown that the vagina presents spots of ulceration, exhibiting a relation 
analogous to that of the trachea in pulmonary phthisis. The Fallopian 
tubes are generally affected coincidently with the uterus. 

The rarity of the affection may be inferred from the fact that, among 
above two hundred phthisical females, Louis only met with three who 
furnished examples of tuberculous disease of the uterus. Considering 
how frequently the functions of the organ are changed, or arrested, during 
pulmonary phthisis, this is not the conclusion to which we should have 
been led by a priori reasoning. 



CANCER. 

Carcinoma of the uterus is a disease of frequent occurrence. Dr. 
Lever 1 has shown that the proportion of carcinoma to other uterine affec- 
tions, is as one to seven, or about thirteen per cent. The period of life 
most obnoxious to it, is that between the fortieth and fiftieth years ; and 
though numerous examples are met with earlier in life, the statement of 
Boivin and Duges, that in four hundred and nine cases they found twelve 
under twenty years of age, can scarcely be credited, unless, as we are 
assured by Dr. Walshe, uterine cancer is more prevalent in the French 
than in our own capital. The analysis of their cases yields the follow- 
ing table : — 

Under 20 years of age ....... 12 cases. 

Between 20 and 30 83 " 

30 " 40 . 102 « 

40 " 50 201 " 

50 « 71 . . . . • . . . . 11 " 

They attribute a great share in the causation to sexual abuse, in which 
view they are perhaps strengthened by the comparatively large number 
of youthful victims. Messrs. Bayle and Cayol, however, emphatically 
deny that their researches lead them to a conclusion of a similar kind, 
but that they have found the disease occur with equal virulence in the 
lowest prostitutes, in married women, and in chaste girls. Dr. Walshe 
asserts that there is no shadow of proof that it ever owes its production 
to disproportionate or intemperate intercourse. Celibacy does not 
appear to favor its development ; the ratio, according to Dr. Lever's 
analysis, is: single women, 5.83 per cent.; widows, 7.5 per cent. ; and 
married females, 86.6 per cent. This is found to be identical with the 
relative frequency of other uterine affections in their respective classes. 
As a rule, the cervix is the part first affected; a feature which broadly 
distinguishes this disease from fibroid growths. A very remarkable 
exception is presented in a specimen of cancer of the body and fundus 
uteri in St. George's Hospital Museum, in which the cervix is entirely 

1 Medico-Chirurg. Trans, vol. xxii. p. 267. 



CANCER. 625 

free from disease (No. 184). The most eminent obstetric physicians are 
of opinion that many instances of so-called cancer are perfectly curable 
by proper remedial agents, from being nothing more than irregular 
thickening, and induration of the cervix, consequent upon chronic in- 
flammatory action. It is, therefore, necessary to be careful in pronounc- 
ing an opinion in the earlier stages of the malady, and not to assume a 
patient to be affected with malignant disease, because of a more hard- 
ened and puckered condition of the os uteri. We possess no means of 
determining the nature of the affection during its first stage with cer- 
tainty; nor is it frequently brought under the notice of the morbid ana- 
tomist. The advance of the deposit, however, and the concomitant sub- 
jective symptoms, the fusion and ulceration, the implication of the 
surrounding parts in the process, the fixation of the womb, and the rigid 
nodulated degeneration of the vaginal mucous membrane, soon enable 
us to form a positive opinion if the disease be malignant. Rokitansky 
has rarely found fibrous cancer affecting the uterus ; this variety con- 
sists of dense, whitish, reticulated fibres, containing in their meshes a 
pale-yellowish, translucent substance ; its limits are not sharply defined, 
but are lost in the uterine tissue. Rokitansky describes medullary car- 
cinoma as the prevailing form of uterine cancer ; appearing as an infil- 
tration of a white lardaceo-cartilaginous, or loose encephaloid matter, in 
which the uterine tissue is lost, and, like the former, giving rise to the 
nodulated surface of the conical portion of the organ generally regarded 
as characteristic of the disease. Colloid cancer, as Dr. Walshe observes, 
is probably never seen in the uterus. 

The degeneration spreads more or less rapidly to the adjoining parts, 
to the vagina, the rectum, the other pelvic viscera and its osseous frame ; 
and, in extreme cases, the whole contents of the abdomen are matted 
together, and present a frightful spectacle of disorganization and can- 
cerous destruction. The ulceration that leads to this result, while it 
gives rise to fetid vaginal discharges, causes very extensive loss of sub- 
stance of the parts first involved: the vaginal portion of the uterus, and 
the vagina itself, are the first to be eroded, and gradually communications 
are established between the various abdominal organs ; the destructive 
character of the affection nowhere manifesting itself with the virulence 
that it here exhibits. Lebert, while admitting the dangerous character 
of the affection when attacking the cervix uteri, denies that it is genuine 
cancer ; he views it as cancroid, and therefore argues strongly in favor 
of local cauterization as a means of cure. He bases this opinion upon 
the frequent absence in cervical cancer of the genuine cancer-cell, and 
upon the rarity of the extension of the disease to the body of the womb. 
We have elsewhere developed our views with regard to the nature of 
cancerous disease generally ; and, as we are unable to admit the exist- 
ence of a specific and uniform cell-growth, characteristic of malignant 
affections, we must decline the inference of Lebert. He regards cancer 
of the fundus as undoubtedly deserving the name applied to it, both 
because the microscope detects the cancer-globule, and because the tissue 
of the organ is throughout degenerated. It is in the nodulated cancerous 
deposits, in this part of the organ, that he has often met with small puru- 
lent deposits. • 
40 



626 THE VIRGIN UTERUS. 

Uterine cancer is ordinarily a primary affection ; carcinoma of other 
organs may be developed simultaneously or consecutively ; but, except 
as a result of the fusion of the former, and its consequent introduction 
into the system, it is not often the case. The average duration of the 
disease is stated by Dr. Lever to be twenty and a quarter months. The 
forms of uterine cancer, which we have spoken of, are not commonly 
liable to induce hemorrhage ; in this respect, it differs materially from 
cauliflower excrescence of the cervix, a disease to which Dr. John Clarke 1 
first drew attention. He describes it as an irregular projection, with a 
base as broad as any other part of it, attached to some part of the os 
uteri. The surface has a granulated feel, and is not tender ; at this 
period the remainder of the cervix exhibits no sensible alteration, but by 
degrees the whole becomes involved. On removal from the body, it col- 
lapses, owing to its vesicular character. The rapidity of the growth 
varies ; several observers differ from Clarke, in regarding it as of a ma- 
lignant character ; a view which is corroborated both by the revelations 
of the microscope and its power of reproduction after having been removed 
by the knife. Mr. S. Lee describes it as consisting of cells covered by 
an epithelial membrane ; and, though he mentions the presence of com- 
pound cells, certainly concludes, from the absence of caudate cells, that 
it is a simple non-malignant structure. Both Rokitansky and Renaud 
regard it as a modification of encephaloid growth, accompanied by a 
remarkable development of capillary loops, closely resembling, as shown 
in the drawing accompanying Dr. Renaud's paper, the vascular arrange- 
ment of the foetal placenta. 

We may not conclude this subject without alluding to a fortunate acci- 
dent in connection with "scirrhous growths" of the uterus, two instances 
of which are recorded by Dr. Ashwell, occurring in females respectively 
twenty-eight and twenty-one years of age. In both, large tumors broke up 
spontaneously, and were discharged per vaginam. Dr. Ashwell is clearly 
of opinion that they were cancerous ; as such, they must have differed 
from the ordinary infiltrated character of uterine carcinoma, a circum- 
stance that only adds to their peculiarity, the more so, as in each case 
the uterus appeared to have recovered its healthy condition. 



THE VIRGIN UTERUS. 

The textural diseases to which the virgin uterus is subject, are not of 
a character to occupy much attention on the part of the morbid anato- 
mist. It is chiefly during the temporary physiological congestion, to 
which the organ is subject after maturity at the menstrual period, that 
morbid influences manifest themselves ; and we then frequently have to 
deal with catarrhal and other slight forms of inflammation of the organ. 
Still, they often become of great importance to the individual, not so 
much from the intensity of the morbid process set up, as from the pecu- 
liar relation which the mucous lining of the womb, as a safety-valve to 
the entire organism, bears to the constitution of the female. The enact- 

1 Transactions of a Society for the Improvement of Medical and Surgical Knowledge, 
vol. iii. p. 321. 



THE VIRGIN UTERUS. 627 

merits of the Mosaic ritual, and the prevailing customs of all civilized 
nations at the present day, equally acknowledge the necessity of attend- 
ing to these indications. The extensive secretory apparatus, in the 
interior of the cervix, is chiefly liable to suffer, and to put on a chronic 
form of catarrh or blennorrhea, marked by a viscid, straw-colored, 
transparent secretion, or by a more or less purulent and sanguinolent 
discharge. The rugae, and deep intervening fossae of the cervix, are 
apt to accumulate the secreted fluids, and the more adhesive they are 
the more a complete plugging up of the os uteri is likely to ensue ; it 
is thus that catarrh may induce sterility ; its extension to the lining 
mucous membrane of the uterine cavity further adds to this peculiarity, 
by impairing its functions, and rendering it incapable to prepare the 
proper nidus for the embryo. The same applies to catarrhal inflam- 
mation passing up the Fallopian tubes. It has been stated that the 
secretion of the cervix uteri is distinguished from that of the vagina, by 
the former being alkaline, while the latter is acid. It certainly is not 
so invariably, for in two cases, which we recently; examined, the straw- 
colored mucus actually within the passage of the cervix was found to be 
strongly acid, while the microscope proved it to be made up exclusively 
of mucus-corpuscles arranged in strings. The effect of continued leu- 
corrhoea of the cervix is to remove the epithelium covering the part, 
and to cause abrasion and ulceration. In the latter case, the villi are 
themselves destroyed; and this, as Dr. Tyler Smith has well shown, 
gives an eaten, corroded appearance to the mucous surface. Dr. Smith 
states that ulcers of the os uteri may be the primary result of inflam- 
matory action, or arise from eruptive disorders of the mucous mem- 
brane, similar to herpes or eczema of the skin. Bat they more fre- 
quently result from the chronic irritation produced by the discharge 
from the cervix. This is confirmed by the fact, that, except in eruptive 
disease, the os uteri is rarely found abraded, unless there is coexistent 
disease of the glandular portion of the cervix. This circumstance, as 
well as the character of the majority of ulcers occurring at the part, 
have an important bearing upon our therapeutic proceedings. Taken 
in conjunction with the statistical records given by Dr. Lee, 1 they go a 
long way to disprove the necessity of the routine treatment of local 
cauterization, which has recently been insisted upon as an almost essen- 
tial element in female therapeutics. The scrofulous diathesis favors 
both the profluvia of the cervix and deeper-seated destruction of its tis- 
sues ; it gives rise to more profound ragged erosion on the surface and 
sides of the os, which, however, is not accompanied by that knotted 
induration which is generally characteristic of the carcinomatous ulcer. 
Nor is it marked by the same tendency to spread and involve adjoining 
parts in its destruction. 

One of the effects of continued irritation of the uterine mucous mem- 
brane is hypertrophy, which induces a species of prolapsus, or the 
formation of polypoid growths at different points of the cavity, and 
occasionally stricture and occlusion, and consequent accumulation of 
fluid in the uterus. 

1 Medico-Chirurg. Trans., vol. xxxiii. p. 261. See also the admirable Lectures by Dr. 
West, very recently published, on Ulceration of the Os Uteri. 



628 THE VIRGIN UTERUS. 

In addition to the forms of ulceration already spoken of, the uterus 
is subject to the specific ulcers of primary and secondary syphilis. 
Under the name of corroding ulcer, Dr. John Clarke has described a 
variety of malignant destruction which differs from genuine carcinoma 
only in not being accompanied by an indurated deposit. No account 
of the microscopic appearances of the part so affected is on record ; a 
link is, therefore, wanting to enable us to pronounce positively as to the 
nature of the disease. It is of very rare occurrence ; Dr. Ashwell, in 
the course of an extensive practice of twenty years, has only twice met 
with it. 

Of the textural affections of the parenchyma of the uterus in the vir- 
gin state little need be said ; a congestion of the organ appears to be a 
frequent source of malaise to the individual, and is recognized by the 
tumid, oedematous feel of the organ, and the injected purplish color of 
the parts when seen by the speculum ; like other mere congestive affec- 
tions, it rarely comes under the observation of the morbid anatomist. 



CHAPTER XXXIX. 

MORBID CONDITIONS FOLLOWING AND PRECEDING 
PARTURITION. 

It is immediately after parturition that the uterus, which during preg- 
nancy has become, as it were, the focus of the entire system, and, having 
completed the great cycle of its duties, is required to lapse into its pre- 
vious dormant state — it is while the organ is yet the seat of increased 
vascular action, and its proper functions may be said to have ceased, that 
morbid influences are received with facility, and produce destructive and 
often rapidly fatal consequences. A large denuded surface is exposed 
to atmospheric contact ; the process of absorption is rapidly going on, 
and any morbific matter, ponderable or imponderable, finds a ready 
recipient in parts in which normally the balance between health and 
disease is very even ; add to this any depressing cause, acting on the 
susceptible mind or constitution of the female, and the balance is rapidly 
turned in favor of the latter. There are two states which are more par- 
ticularly liable to supervene immediately after parturition, which are 
each of them a source of danger, by the hemorrhage they give rise to. 
The one is, atony or defective contraction ; the other, spasm or irregular 
contraction of the uterus. In the one case, we find the uterus maintaining 
its dilated condition, its walls are flabby and soft ; in the other, various 
irregular forms, to which the term hourglass contraction has been applied, 
present themselves. Both may become the subject of post-mortem ex- 
amination, and instances are preserved in the museums of pathological 
anatomy. They are both allied to that influence which the vital powers 
sometimes sustain after parturition, from the severity of the shock to the 
system, and which, in its extreme form, may give rise to a fatal issue 
without producing any other symptoms but those of mere prostration. 
The various forms of inversion of the organ, which are in part due to a 
combination of these conditions, we have already alluded to. 



PUERPERAL INFLAMMATIONS. 

While the subject of fevers generally, and their proximate causes, are 
still under discussion, the nature of puerperal fever has been established 
with certainty to consist in inflammation of the uterus and its appendages ; 
the various forms assumed by the febrile affections that follow parturition 
depend, in a great manner, as Dr. Lee observes, upon the serous, mus- 
cular, or venous tissues of the organ having become affected. Of forty 



680 PUERPERAL INFLAMMATIONS. 

cases of puerperal fever, that had come under the notice of Dr. Lee, 
when he published the result of his researches, the peritoneum and uterine 
appendages were found inflamed in twenty-six ; in fourteen, there was 
uterine phlebitis ; in eight, inflammation and softening of the muscular 
tissue of the organ, and in four the absorbents were distended with pus. 
Almost the only exception among the classical writers on the subject is 
Dr. Copland, who asserts the occasional occurrence of a rapidly fatal 
form of puerperal fever in lying-in hospitals, in which there is no local 
lesion, but where there is a remarkable alteration of the blood, general 
lacerability of the tissues or loss of their vital cohesion soon after death, 
with a dirty, muddy, offensive, and sometimes serous effusion into the 
serous cavities. According to the predominant symptoms, nosologists 
have divided puerperal fevers into the inflammatory and typhoid, as 
Gooch and Boivin, and Duges ; into the inflammatory, the ataxic, and 
adynamic, as Tonnelle has done; or into the inflammatory, the synochoid, 
and adynamic or malignant, as proposed by Dr. Copland. Those who 
study the histories of the various epidemics of this fearful malady, will 
observe that, w r hile there is a general resemblance between the local 
lesions, which more immediately concern us, the morbid symptoms during 
life vary according to the genius epidemicus, which is influenced by the 
predisposing as well as the exciting causes that are at work in each case. 
Here, however, there is also a general resemblance, which has been satis- 
factorily shown to present the same character as that of the erysipelatous 
constitution. That this consists in some poisonous agent capable of being 
communicated from one person to another, and analogous if not identical 
with the effluvia of putrefying animal matter, is rendered probable by 
the difficulty of arresting the spread of the disease when it has once 
appeared in a lying-in hospital; the strong evidence we possess of the 
communication of the infection from one person affected to another par- 
turient female at a distance, through the intervention of the medical man, 
and by the direct effect of preventive means adopted with a view to de- 
stroy noxious effluvia and prevent contagion. Dr. Gordon, in his essay 
on puerperal fever, gives his adhesion to the view that erysipelas and 
puerperal fever possess strong analogies, and that they are concomitant 
epidemics. He observed the two together in Aberdeen, where they com- 
menced together, kept pace together, arrived at their acme and ceased 
at the same time. Our limits forbid our accumulating evidence on this 
point ; we may, however, add the testimony of one more observer in the 
Irish capital, Dr. Beatty, who, speaking of two epidemics that he wit- 
nessed, states that both attacks took place in January, and at each time 
erysipelas was raging as an epidemic in the surgical wards of the hos- 
pitals, and diseases of a typhoid type were very prevalent in the city. 
The strongest proof of the septic character of the disease has recently 
been afforded by the observations of Dr. Semelweiss, that, in the fatal 
puerperal fever which has long more than decimated the obstetric patients 
of the Vienna hospstal, 1 the poison was the cadaveric matter communi- 
cated by the students, who had previously been engaged in post-mortem 

1 See Dr. Routh's paper on the "Endemic Puerperal Fever of Vienna," Medico-Chir. 
Trans, vol. xxxii. p. 27. 



PUERPEEAL INFLAMMATIONS. 631 

examinations, to the females. The adoption of the proper precautions 
suggested by Dr. Semelweiss, as we have already shown in the chapter 
on phlebitis, at once reduced the mortality. Hence, it is manifest that 
one source of danger may be easily guarded against, and accoucheurs 
certainly cannot be too careful to cleanse themselves thoroughly after 
making post-mortem examinations, and handling putrid matter. Nor 
does it appear that this is enough, but that the medical man should, in 
these cases, be particularly on his guard to avoid every other possible 
source of contagion; "in the hour of the mother's peril," to use Dr. 
Holmes's eloquent words, "God forbid that any member of the profession 
to whom she trusts her life, doubly precious at that eventful period, should 
hazard it negligently, unadvisedly, or selfishly." 

When the uterus has itself been the main seat of the puerperal in- 
flammation, we find that an exudative process has given rise to the 
formation of a yellowish, or greenish, more or less gelatinoid lining on 
its internal surface, inducing a ragged, patchy appearance. This exu- 
dation may be easily detached from the subjacent mucous membrane, 
which according to the intensity of the disease is more or less reddened, 
tumefied, and softened. This condition may penetrate to the deeper 
tissues, and involve the entire thickness of the uterus, which will then, 
also, be more or less softened and discolored, infiltrated with a low 
sanious product, and even converted into a mere pulp. But we must 
guard against mistaking the dirty-colored, brownish, flocculent matter 
that is found investing the inner surface of the uterus soon after deli- 
very, and which is merely the residue of the decidua, for the product of 
disease. This has been done by Boer and others, who have considered 
it as a proof of what has been termed putrescence of the organ. The 
rugged appearance of the part to which the placenta was attached also 
simulates this appearance. Dr. John Clarke states that this is only 
the remains of the maternal portion of the placenta, and of the coagula 
of blood left after its separation, which may be easily scraped off, show- 
ing the healthy surface underneath. He also testifies that he never 
met with mortification in any part of the uterus except in one instance, 
where it was manifestly attributable to the employment of instruments 
during labor. Bokitansky describes putrescence as the lowest form of 
uterine inflammation, and states that it differs from ordinary sphacelus; 
in this case, the internal layer of the organ is covered with a thin, 
opaque, or more dense product, varying in color from pale green to 
dark brown, beneath which the tissue, to a greater or less depth, is 
converted into a similar pulp. Small abscesses are sometimes found in 
the muscular tissue, without any perceptible change in the surrounding 
parts ; generally, however, the structure of the muscular fibre is en- 
tirely destroyed. Tonnelle, who has analyzed two hundred and twenty- 
two cases of puerperal fever, in which he performed post-mortem 
examinations, found the womb affected with simple metritis in seventy- 
nine ; in twenty-nine there was superficial, in twenty deep softening. 

The more the inflammation presents a sthenic character, the more 
the products will resemble those of healthy inflammatory action; and, 
conversely, the more ataxic or adynamic the disease, the further they 
will be removed from that type. Rokitansky considers metritis to be 



632 METROPHLEBITIS. 

essentially of a croupy character, the peculiar nature of which, he says, 
is fixed by the form of the product, the condition of the subjacent tis- 
sues, and especially by the state of fusion exhibited by them. 



METROPHLEBITIS. 

Of the tissues entering into the constitution of the uterus in preg- 
nancy, and immediately after parturition, none appear to possess a 
greater proclivity to be attacked with inflammation than the venous 
channels and the lymphatics ; both may be primarily and coincidently 
affected, which is generally the case, or they may be attacked separately 
and secondarily. According to the observations of Tonnelle, who 
found that, of two hundred and twenty-two fatal cases of puerperal 
fever, one hundred and thirty-two presented inflammation of the veins 
and lymphatics of the uterus, phlebitis alternates with inflammation of 
the muscular tissue; during the great epidemic which this author fol- 
lowed in 1829, the latter occurred very frequently at the commence- 
ment of the year, and disappeared in July and August, and recurred in 
the months of September and October. The intervening summer months 
were characterized by the frequency of phlebitis. 

Uterine phlebitis is generally set up within the first twenty-four hours 
after delivery, and though it cannot be invariably traced to the orifices 
of the veins, where the placenta adhered, it is probable that the intro- 
duction by them, of foul exhalations or secretions into the vessels, is the 
main cause, both of the local and the general effect. In the more favor- 
able cases, adhesive inflammation prevents the spread of the malady: the 
danger is increased if pus forms, and the most virulent symptoms result 
if the product is of a sanious or septic character. Dr. Lee is of opinion 
that it not unfrequently occurs without proving fatal, and he bases his 
supposition upon the fact of calcareous concretions and disorganizations 
of various kinds being frequently met with in the spermatic and hypo- 
gastric veins of aged females, which he attributes to previous phlebitis. 

In uterine phlebitis we find the organ studded with small abscesses, 
which may be traced to the vessels ; these present the various appear- 
ances described under phlebitis, modified according to the character or 
duration of the disease in the individual case. When the lymphatics 
are affected, they, like the veins, become varicose, and thickened and 
distended with the purulent or sanious products of inflammation. 

Uterine phlebitis is very commonly followed by metastatic abscesses ; 
it is to the occurrence of the secondary purulent deposits, and the coin- 
cident infection of the entire system, that the main source of danger may 
be attributed. The more adynamic the type of the disease, the more 
probable it is that pus will be absorbed, and the local circumscription of 
the disease prevented. 



PUERPERAL PERITONITIS. 633 



PHLEGMASIA DOLENS. 



As a disease immediately secondary to uterine phlebitis, we must now 
turn to the consideration of Phlegmasia alba dolens ; Dr. Davis deserves 
the credit of having first shown it to consist in inflammation of the crural 
vein ; Dr. Lee first succeeded in tracing the uterine origin of this affec- 
tion anatomically ; he demonstrated the inflammation commencing in 
the branches of the hypogastric vein, and subsequently extending from 
them to the iliac and femoral trunks of the affected side. The cellular 
tissue surrounding the vein participates in the inflammation, and that, 
as well as the impeded return of the venous blood to the heart, gives 
rise to much oedema of the limb, and condensation of all the tissues. 
This may be followed by suppuration, or sloughing ; it may terminate 
in a complete cure, by resolution ; or, in a partial recovery, with ob- 
literation of a portion of the vein, and permanent induration of some of 
the soft parts. In a case examined twenty-one months after the attack, 
Dr. Lee found the external iliac vein, with its subdivisions, and the 
upper part of the femoral, converted into a ligamentous cord, so that it 
could only be distinguished from the surrounding cellular tissue by 
careful dissection. No traces of the entrance of the common iliac into 
the cava could be made out. The left side has a greater tendency to 
become affected than the right. The pathology of phlegmasia dolens is 
considered, by Dr. Copland, 1 of a more complete nature than we have 
described it; while he does not deny that it most frequently consists in 
inflammation of the femoral and iliac veins, he thinks it occasionally 
commences in the nerves, and sometimes in the lymphatics and glands, 
the veins then being secondarily affected. Nor does Dr. Copland admit 
that it is always referable, for its origin, to the uterus ; he attributes 
the lesions in the veins, in some instances, to the consequences of pro- 
longed pressure, or to this cause, and the sudden removal of that pres- 
sure, the disease originating in the iliac and femoral veins ; again, he 
is of opinion that it may originate in lesion of any of the pelvic viscera, 
or of the parietes of the pelvis, or that it may be unconnected with any 
affection of this character, and owe its origin to rheumatic influences 
directly acting upon the lower extremity. 



PUERPERAL PERITONITIS. 

The serous membrane of the abdomen is very frequently attacked by 
inflammation in the puerperal state. Peritonitis occurs primarily or 
secondarily, but the form in which it presents itself, as well as its ex- 
istence, depend much upon the character of the epidemic ; thus, while 
M. Tonnelle found evidence of peritoneal inflammation in 197 out of 
222 cases, Dr. Bartsch, in Vienna, under whom 109 fatal cases of puer- 
peral fever occurred in the fourteen months preceding December 31st, 
1834, found that it seldom exhibited the form of peritonitis, but gene- 

1 A Dictionary of Practical Medicine, yoI. iii. p. 254. 



634: PUERPERAL PERITONITIS. 

rally appeared as metrophlebitis. If we examine the table of puerperal 
epidemics, collated by Dr. Churchill, 1 we find that, while of forty-three, 
in which the predominant post-mortem appearances are given, only four 
w r ere characterized by uterine phlebitis, twenty-nine are stated as peri- 
tonitis. It is then, undoubtedly, the lesion most commonly associated 
with puerperal fever. It may be limited to the surface of the organ, 
and more particularly to the part surrounding the neck, or it may in- 
volve more or less of the entire sac. In two epidemics, it appears that 
the omentum was the seat of election. 

Dr. Joseph Clarke states that the surface of the stomach, the liver, 
the spleen, omentum, great and small intestines, uterus, and the internal 
peritoneal lining of the muscles of the abdomen, will, in their turns, or 
altogether, be found to partake of the disease ; but, as far as his experi- 
ence goes, no part more than another. 

The membrane never exhibits much vascularity, and in the low typhoid 
forms there is a remarkable absence of congestion and redness. In the 
more sthenic forms, which approach to the character of ordinary peri- 
tonitis, the greater vascular action is accompanied by the production of 
lymph and pus of a healthy appearance, adhering to the surfaces and 
matting them together. The ordinary character of the exudation, how- 
ever, is a copious effusion of an aplastic character; the abdomen then 
contains from a few ounces to several quarts of serum of a dirty-yellow, 
greenish, or brownish hue, in which flocculent particles of lymph are 
floating, while but small patches of a thin non-coherent exudation are 
observed on the peritoneal sac. A remark of Dr. Hodgkin, 2 in refer- 
ence to the small quantity of tender false membranes often met with 
accompanying serous effusion into the peritoneum applies here; it is to 
the effect that, though unquestionably of inflammatory origin, they are, 
in many cases, to be regarded as the result of a secondary action which 
the presence of the fluid has exerted in the peritoneum. 

The smell of the fluid is also distinctive; it will be recognized when 
once noticed, as it differs from anything met with in the human body, 
in health or disease. The fluid is described by the older authors as of 
a creamy character ; hence, the long prevailing fallacy that it was con- 
nected with an actual metastasis of milk, which was in a measure sup- 
ported by the failing supply of the mammary secretion observed as one 
of the first symptoms of the disease. The serum contains a compara- 
tively small portion of albumen, offers an acid reaction, and is said to 
possess a very salt taste. Beyond an analysis by Dr. Pearson, which 
is not equal to the requirements of modern chemistry, we have not met 
with a minute determination of its constituents. The ovaries and Fal- 
lopian tubes are very frequently found inflamed in puerperal inflamma- 
tions; neither, however, are ever primarily affected, but coincidently 
with, or consecutively to, the diseased conditions just considered. 

1 Essays on the Puerperal Fever, &c, by Fleetwood Churchill, M. D. (Sydenham 
Society), p. 31. 

2 Lectures on the Serous Membranes, &c, p. 150. 



DISEASES OF PREGNANCY. 635 



COMPLICATIONS OF PUERPERAL FEVER. 

"We conclude this subject by a brief glance at the morbid processes 
accompanying puerperal fever in other organs, in which we shall closely 
adhere to Rokitansky. The entire track of the intestinal mucous 
membrane is slightly reddened and invested by a secretion of a thin 
serous or viscid gelatinous or more or less purulent character ; the 
mucous membrane fuses, and the submucous tissues are infiltrated. To 
this circumstance we attribute the diarrhoeas accompanying puerperal 
fever. The mucous membrane of the colon occasionally presents a 
dysenteric exudation, resembling that found on the internal surface of 
the uterus. Similar processes are also met with on other mucous sur- 
faces, as of the respiratory, urinary, or oesophageal tracts. Dr. Clarke, 
in alluding to the occurrence of aphthas in the mouth and fauces, as a 
frequent symptom in puerperal fever, and to their also being found at 
the anus, denies the correctness of the statement that the aphthae go 
through the whole intestinal canal, as it is not borne out by dissection. 
The serous and synovial membranes of the whole system sympathize 
with the morbid processes of puerperal fever; the pleura are almost 
constantly found to contain exudations similar to those met with in the 
peritoneum ; the pericardium contains them less frequently ; the articu- 
lations very commonly exhibit exudations of a fibrinous or purulent 
character. The dura mater often presents a slight reddening, with a 
thin, soft exudation. To the secondary abscesses, resulting from capil- 
lary phlebitis by the extension of the inflammation of the uterine veins, 
or by the absorption of pus, we have already alluded. Rokitansky de- 
scribes a black softening of the mucous lining of the fundus ventriculi, 
or of the oesophagus, indicated during life by black vomit, as a frequent 
occurrence. The stomach may become ruptured, and the black matter 
be thus effused into the abdominal cavity. 

The blood exhibits various changes ; its fibrinous coagula present a 
viscid, greenish-white appearance, or the coagula are scanty, gelatinous, 
and soft. The blood is of a dirty brown red, or chocolate color, and 
glutinous, or it is much attenuated and transudes all the tissues. The 
fibrin may form vegetations on the valves from mere mechanical deposi- 
tion. The jaundice often affecting women during the puerperal state, 
is not dependent upon an appreciable lesion of the liver, but upon 
pyasruia. 

DISEASES OF PREGNANCY. 

The consideration of the morbid processes complicating parturition is 
appropriately followed by an account of the diseased conditions met 
with in the placenta and in the ovum; we shall, at the same time, touch 
upon extra-uterine pregnancy. , 



636 THE PLACENTA. 



THE PLACENTA. 

The placenta varies much in size within the limits of health. Its 
position differs also considerably without inducing any detriment to 
mother or child ; but when placed near or over the os uteri, the fre- 
quent hemorrhages that occur endanger the lives of both. The umbilical 
cord, instead of being attached to the centre of the placenta, is some- 
times inserted at the edge ; this gives rise to what has been termed the 
battledore placenta, a deviation which, though not in itself perilous, 
may become so by rough manipulation after the birth of the child. The 
same applies to those cases in which the vessels of the cord are divided 
before they reach the placenta, or are inserted into the membranes. 
Other irregularities of the cord consist in its being excessively short, or 
extravagantly long, and in its being tied into knots. The extremes of 
length on record are two inches and fifty-seven inches. 

Concussion, or other external violence, is a frequent cause of partial 
separation of the placenta, inducing extravasation into the tissue, and fre- 
quently giving rise to abortion. That the placenta is the seat of nume- 
rous morbid processes, may be inferred from the close relation it bears 
to the nutrition of the foetus, the frequency of foetal disease, and the 
necessary transition through the placenta of any morbific agent, which 
induces the latter. It is only, however, very recently that the attention 
of pathologists has been directed to the diseased conditions of this 
organ ; our knowledge of the morbid changes to which it is liable is, 
therefore, as yet, very limited. 

Professor Simpson 1 describes congestion of the placenta as affecting 

Fig. 329. 




Sectional riew of atrophied placenta. The atrophy and fatty degeneration of the maternal and foetal por- 
tions were caused by a fibrinous layer on the uterine surface, a. Fibrinous deposit, b. Maternal portion of 
placenta, c. Foetal portion. 

the maternal or foetal portion, causing the external surface of the organ 
to assume a more or less deep violet, and, sometimes, almost livid color, 

1 Edinburgh Medical and Surgical Journal, vol. xv. p. 265. 



THE PLACENTA. 637 

the internal structure presenting a deep-purple hue, from the vessels 
being overcharged with blood, while the substance is heavier and more 
solid than natural. One of the sequelae of congestion is hemorrhage 
into the body, or on the surface of the placenta, varying much in extent. 
The effused blood undergoes the changes usually traced in coagula, and, 
when there are several fibrinous remains, they cause a tuberculated 
appearance. 

Inflammation of the placenta begins from the uterine surface, or in 
the substance of the organ, and presents the various stages seen in other 
parts, producing local or general hepatization, effusion, irregular adhe- 
sions, and secondary degenerations. 

Inflammation may attack the whole, or a portion of the placenta, 
causing a deposit of fibrin. The effusion and compression of the tissues 
will vary according to the extent of the inflammation, causing more or 
less obliteration of the bloodvessels. In an extreme case, we find a cap- 
sule of dense lymph encasing the maternal surface, the whole is con- 
siderably reduced below the normal size, and the soft, spongy texture, 
is converted into a compact, splenified mass. If confined to individual 
lobules, the alteration will be limited in a corresponding degree. Those 
instances of adherent placenta which are the source of so much anxiety 
to the accoucheur, are probably referable to a prior inflammatory attack, 
gluing the afterbirth to the uterus. Professor Simpson admits the 
occurrence of total absorption of a placenta as one of the consequences 
which may result from the agglutination of the afterbirth to the uterus. 
A third stage of inflammation is occasionally met with in the shape of 
abscesses or of purulent infiltration ; it is also stated to give rise to the 
effusion of pus between the two surfaces of the uterus and placenta. 
Rokitansky describes suppuration occurring here in the form of circum- 
scribed abscesses, or of diffused infiltration and fusion. Fatty degene- 
ration of the placenta, to which Professor Kilian and Dr. Barnes have 
recently drawn attention, is probably to be explained as the molecular 
disintegration resulting from the deposit of fibrin in the cells surround- 
ing the villi of the chorion ; and not as a primary deposit of oil within 
the placental capillaries, a view more fully developed by Dr. Handfield 
Jones, 1 in a paper on fatty degeneration. If portions of a placenta, 
thus degenerated, be thrown into water, " the first thing which strikes 
the observer," to employ the words of Dr. Barnes, 2 is, u that the tufts 
of villi do not expand or float out in the same way as in the healthy 
placenta, and, on endeavoring to separate the fragments into its com- 
ponent villi with needles, the extreme brittleness of the whole structure 
becomes apparent." Examined by a high power, u we observe : (1) that 
the villi are thickly studded with innumerable, minute spherules of oil; (2) 
the chorion is much altered ; it is thickened and destitute of nuclei ; (3) 
the walls of the vessels no longer contain nuclei, these having, in all pro- 
bability, become degenerated into spherules of oil ; (-1) the spherules of 
oil are contained, some in the chorion, some in the walls of the blood- 
vessels, and many in the intervals or spaces between these ; (5) the 

1 Medico-Chirurgical Review, April, 1853. 

2 Medico-Chirurg. Trans., vol. xxxiv. 



638 THE FCETUS. 

cavities of the vessels are almost invariably free from fatty deposition ; 
(6) the vessels are destitute of blood. 

The placenta is liable to other morbid processes, of a degenerative 
character; the vessels may undergo cretification, and osseous deposits, 
of a nodulated form, are met with imbedded in the tissue; the villi of 
the chorion are not unfrequently found to have become converted into 
oval, pedunculated, serous vesicles, or hydatids, clustered together like 
a bunch of grapes; the cysts vary in size, from a pin's head to a filbert, 
and more, and they may amount to several hundred. This pathological 
condition has received the name of the vesicular mole; it is to the expul- 
sion of a mass of this kind, that the fabulous accounts of women having 
given birth to several hundred children are attributable; the cysts having 
been regarded as ova, and these having been magnified into infants. 
Two beautiful specimens of the disease are preserved in St. George's 
Hospital Museum. 

It is the opinion of several distinguished accoucheurs, that the vesicular 
mole may occur in the virgin state; in that case, the explanation we 
have offered is necessarily incorrect, and we must seek for it in some 
derangement of the uterine tissues. 

Rokitansky denies the occurrence of tubercle in the placenta. The 
only instance on record that we have met with, is one described by M. 
Hardy, 1 as having been found in a phthisical female, aged thirty-five, 
who died suddenly, in the seventh month of pregnancy. The Cesarean 
operation was performed immediately after her decease, and the foetus 
was dead. Besides the ordinary appearances of pulmonary phthisis, 
the external surface of the uterus exhibited numerous small projections, 
which proved to be crude tubercles; there were none in the tissue, or on 
the internal surface ; in the placenta, there were from eight to ten large 
tubercles, some as large as a pea, two nearly the size of a nut, of a 
whitish color, and dense; the foetal surface of the placenta presented to 
the finger the sensation of a large number of miliary tubercles. The 
organs of the foetus were normal. 



THE FCETUS. 

The foetus is liable to become the seat of morbid processes at every 
stage of its development, and in every tissue and degree; giving rise, at 
the earlier period of its existence, to an entire destruction of the forma- 
tive nisus, or to partial arrests of development in individual parts, some 
of which we have had occasion to allude to in speaking of the malforma- 
tions of different organs — inducing, in its later intra-uterine existence, 
phenomena of disease resembling those met with in the human being 
after birth. It remains for future inquirers to determine more accurately, 
not only the exact pathological character of the different lesions, but 
also the primary or secondary relation borne between the morbid states 
of the placenta and the foetus. Many of the masses that have passed 
under the name of moles, have originated in a blight of the ovum ; "the 

1 Archives Generales de Medecine, 1834, vol. v. p. 244. 



THE FCETUS. 639 

embryo," as Dr. Ashwell describes it, "having died early, the ovum has 
increased in size and solidity, not by a process of growth, as in natural 
pregnancy, but by the effusion of coagulable lymph, from inflammation 
of the lining membrane. This forms successive layers over the surface 
of the dead ovum, giving it, eventually, a great degree of consolidation. 
Some of these masses exhibit no cavity, but the chorion and amnion are 
demonstrable, although the enveloping lymph may be one or two inches 
in thickness." Dr. Ashwell describes another form of moles, which 
does not owe its existence to conception, and may be attributable to an 
accumulation of fibrinous exudation within the cavity of the uterus, in- 
duced by croupy inflammation of the lining membrane. Two specimens 
of this may be seen in St. George's Hospital Museum (Nos. 58 and 142). 

Every organ and tissue of the foetal body may become the seat of 
atrophy or hypertrophy; the latter may be characterized as actual ex- 
cess of one or more organs, as we often meet with in the phalanges. 
Numerous distortions, curvatures, even fractures, and other solutions of 
continuity, 1 demand the attention of the medical man immediately after 
the child's birth. Atrophic conditions are, generally, referable to dis- 
eased states of the placenta, which interfere with the nutrition of the 
child, and cause it to perish, or merely prevent its normal development. 
Cases are recorded in which such atrophic foetuses have been borne the 
full period, though their death had taken place early in pregnancy; 
these, as Dr. Montgomery 2 remarks, illustrate the necessity of carefully 
examining into the state of the foetal appendages as to their healthy 
condition or otherwise, before we venture to pronounce an opinion on 
the time that has elapsed since conception, merely from the size and 
general appearance of an ovum or foetus shown us. In an accident of 
this kind, an error in judgment might seriously, though unjustly, affect 
the reputation of a female whose husband had died or left home shortly 
after conception. 

The curvatures that the foetus is most commonly subject to are, those 
of the lower extremities — these, as well as the dislocations of the astra- 
galus, the elbow, and other parts that frequently come under the notice 
of a surgeon, are attributed to violent contractions of the uterus, or to 
convulsions affecting the foetus. Of the hernise, to which, as congenital 
affections, we must allude, umbilical is a frequent, and diaphragmatic 
the rarer form ; both are the result of imperfect development of the 
parietes, which in each case respectively ought to completely close in 
the abdominal viscera. In the former, the intestines, to a greater or 
less extent, pass through the umbilical opening, and occupy a pouch 
formed by the cutaneous coverings of the abdomen ; in the latter, they 
enter the thoracic cavity, where they displace the lungs and the heart ; 
they commonly, though not necessarily, cause the death of the foetus. 
The brain occasionally protrudes through the cranium, giving rise to 
hernia cerebri; this, however, must not be confounded with a tumor, 
which often forms on the head of the infant, simply owing to the me- 
chanical pressure exerted upon it during parturition, and the conse- 

1 See a remarkable case that was brought before the Medico-Chirurgical Society, by 
Mr. T. D. Jones. Medico-Chirurg. Trans, vol. xxxii. p. 59. 

2 Art. Foetus, in Dr. Todd's Cyclopaedia of Anatomy and Physiology. 



640 THE FCETUS. 

quent extravasation, and known as cephalhematoma. Encephalocele 
is described by Dr. Montgomery as, at first, a rather tense, smooth, and 
semitransparent tumor, giving generally a more or less distinct sense of 
fluctuation ; in shape, the tumor is globular or oval, and frequently 
tapers to a neck, where it issues from the head, at which point a circu- 
lar aperture can be detected in the bone, the edges of which are, in 
general, smoothly rounded oif. The defect in the cranial bones, giving 
rise to this malformation, is analogous to that upon which spina bifida 
depends; here, there is a deficiency in the arches of one or more verte- 
brae, allowing a protrusion of the dura matral sheath of the canal, and 
the arachnoid lining, in which an accumulation of the spinal fluid takes 
place. The arachnoid often forms at the most projecting parts of the 
tumor the only investment, both the skin and the dura mater being 
thinned down gradually, and at last entirely lost. The fluid, in its 
turn, presses upon the cord, and more or less displaces it. When it 
occurs in the lumbar region, its ordinary site, the divided cauda equina 
may be seen, as Dr. Bright has shown, 1 adherent to the sac, and in- 
duces the erroneous opinion that the appearance is due to the nerves 
distributed over the sac being turned backwards from their natural 
direction. When there are several deficiences in the osseous canal, the 
fluid communicates between the different tumors ; the entire column 
may be deprived of its spinous processes and their arches, so that the 
tumor occupies the whole region. Spina bifida is often associated with 
hydrocephalus. 

One of the most remarkable occurrences in intra-uterine life, is the 
phenomenon of spontaneous amputation of a limb; this is sometimes 
complete — the severed extremity being entirely detached, and leaving 
a stump, in which the healing process is perfected; — at others only par- 
tial, the stricturing band not having cut through all the tissues. It is 
generally the left lower extremity that suffers; and Dr. Montgomery 
has demonstrated the fact of its being due to the umbilical cord being 
twisted round it, and not, as has been suggested by others, to gangrene, 
or the accidental formation of ligamentous bands. He expresses his 
conviction that many of the cases of apparent arrest of development 
may be set down to this cause, the amputated member not having been 
found, either from its being atrophied or buried in coagula, and from 
the separation having been effected at the early stages of pregnancy. 

Numerous observations are recorded by authors, evidencing the oc- 
currence of the inflammatory process in the foetal viscera. Peritonitis, 
with its various sequelae; gastro-enteritis, followed by ulceration; in- 
flammatory lesions of the liver, pneumonia, and pleurisy; abscesses in 
the lungs, the thymus, thyroid glands, and supra-renal capsules, and 
pericarditis ; have each been proved to occur in the foetus, by Desor- 
meaux, Billard, Simpson, Cruveilhier, Montgomery, and other patholo- 
gists, to whose works we must refer for further .particulars. The same 
applies to the various cutaneous affections of a syphilitic, variolous, or 
uther character. Tubercular deposits and cancerous growths have been 
seen, but they are both extremely rare. Nor is it compatible with our 

1 Reports of Medical Cases, vol. ii. p. 640. 



EXTRA-UTERINE PREGNANCY. 641 

limits to do more than allude to the endless varieties of monstrosities 
which, from the causes mentioned, or from reasons to which pathology 
offers no clue, affect the unborn child. 



EXTRA-UTERINE PREGNANCY. 

Five varieties of extra-uterine pregnancy are assumed to occur; in 
the Fallopian tubes, in the walls of the uterus, in the ovaries, in the 
peritoneal cavity, and in the vagina. We have not met with a well- 
authenticated instance of the last form, and the occurrence of ovarian 
pregnancy has also been denied by authorities like Yelpeau and Kilian. 
The danger to mother and child is almost equal in each variety ; in 
fact, there is only one case on record in which both have survived; this 
was one of peritoneal or abdominal pregnancy, which occurred to Dr. 
P. L. Heim, and in which the Csesarean section was successfully per- 
formed. 1 The accident most'frequently met with is the Fallopian tube 
pregnancy. In this case the ovum is arrested in its descent into the 
uterus, and the process of growth and development progresses as if it 
had reached its proper nidus up to the period of its discharge. The 
tube is distended, and its walls become hypertrophied ; the changes in 
the maternal system, though sometimes accompanied by certain anoma- 
lous symptoms, are those met in ordinary pregnancy ; there is general 
turgescence of the mammae and the uterus, and in the latter organ it 
has long been taught that a decidua is formed, as if it contained the 
foetus. Denman, Baillie, William Hunter, and Elliotson, have met with 
instances in which the decidua was present ; other cases have been 
recorded by Mr. Langstaff and Dr. Lee, in which it had not formed. We 
have ourselves examined a preparation in St. George's Hospital Museum 
(No. 2,718), in which the decidua is wanting ; nor does it seem difficult 
to understand that in one instance the sympathetic irritation should be 
set up by which this membrane is produced, and that it should fail in 
others. The development of the Fallopian tube does not keep pace 
with that of the ovum, and in the second or third month rupture gene- 
rally takes place, the foetus escapes into the abdominal cavity, and the 
mother sinks from the shock, the hemorrhage, or the peritoneal inflam- 
mation that ensues. In the majority of instances the right tube is the 
one affected. Rupture does not appear to be the invariable issue. In 
the Royal College of Surgeons (preparation No. 2,719), we find a foetus 
almost completely developed, but compressed and dried, which is stated 
to have been removed by operation from the Fallopian tube fourteen 
years after gestation ; the patient recovered, and lived for a long time 
after at Hamburg, where the operation was performed. This specimen 
is a good instance of what has been termed a lithopsedia, a stone-child; 
the parts intervening between the extremities are ossified, and nutrition 
appears to have been thoroughly arrested. These lithopsedia are some- 
times retained within the uterus, as the remarkable preparation in the 

1 Rust's Magazin fur die gesammte Heilkunde, vol. iii. 1817. 

41 



642 THE FALLOPIAN" TUBES. 

same museum (No. 2,720) proves, of which Dr. Cheston 1 has given a 
detailed account. The mother, at the age of twenty-seven, carried her 
fourth child to the full period, had labor-pains, but no child was born. 
She recovered, and died paralytic at the age of eighty. The uterus 
was found to contain an osseous sac adherent to the surrounding part, 
and resembling a middle-sized human cranium. The cyst seemed to 
have absorbed all the parts in contact with it, and contained a foetus in 
the same position as that in utero. The brain, lungs, and liver, pre- 
served almost their natural appearance; but there was no trace of blood, 
nor any remains of membranes, placenta, or umbilicus. The osseous 
sac, with the foetus, weighed three pounds, one ounce, four drachms. A 
similar instance of thirty-two years' duration is described by Prael. 2 

The terminations of Fallopian tube gestations alluded to are not the 
only issue which we meet with. Adhesions form with different parts of 
the parietes, and the foetus having been broken up by ulcerative dis- 
junction, the parts may be discharged piecemeal, whereupon the cyst in 
which they were contained contracts, and the mother survives. In this 
way the foetus has been eliminated by the rectum and the umbilicus. 
The above remarks also apply in the main to abdominal gestation ; here 
the ovum, probably owing to a want of that erectile tone in the fim- 
briated extremity of the tube by which in ordinary pregnancy it is made 
to embrace the ovary when conception is effected, falls into the peri- 
toneal cavity, the development proceeds up to a certain point, and death 
ensues from peritonitis, or hemorrhage, or else the foetus is eliminated 
in the manner above described. 

Pregnancy in the parietes of the uterus probably consists in an arrest 
of the ovum at the point at which the tube is inserted into the uterus; the 
sac, therefore, consists chiefly of the uterine tissue; but, owing to the irre- 
gular development of the organ, the process cannot run its course to the 
full period in the normal manner, the thinner portion gives way early 
in pregnancy, and death ensues, as in the other cases, from rupture and 
hemorrhage. 

THE FALLOPIAN TUBES. 

The Fallopian tubes are liable to various forms of inflammatory action. 
Catarrh and exudative inflammation not unfrequently cause a temporary 
or permanent closure of their channel, which prevents conception, and 
may lead to dropsical accumulations and other morbid conditions. Thus, 
the fimbriated extremities may become agglutinated to the ovaries, the 
broad ligament, or the uterus itself; or obliteration may occur at one or 
more points within the passage; unless the mucous membrane of the 
part still patent be deprived of its functions, the continued secretion 
will cause distension, simulating a cyst-formation; we have seen a case 
of dropsy of the Fallopian tube, in which the distension amounted to 
about five inches in diameter. At other times, according to Rokitansky, 
several saccular dilatations form between the separate angles and pro- 

1 Medico-Chirurgic.nl Transactions, vol. v. 

2 De Foetu, duo de triginta Annos in Utero detento. Goettingen, 1821. 



THE FALLOPIAN TUBES. 643 

jecting duplicatures of the tubal parietes, and give rise to an imper- 
fectly loculated pouch, which, as in the former case, may contain mucous 
matter of a more or less purulent character, or fluid of an heterogeneous 
constitution. These morbid contents are sometimes poured into the 
uterus, probably in consequence of the occlusion only having been ef- 
fected by inspissated mucus ; a less favorable issue, is rupture of the sac, 
and effusion of its contents into the abdominal cavity. 

Cysts often affect the fimbriated extremities of the tubes ; they are 
pediculated, and do not attain a large size. The Fallopian tubes may 
also be the seat of fibroid growths, carcinoma, and tubercle. Both the 
latter are commonly secondary to uterine disease of the same character. 
Dr. Lee states that carcinoma may originate in this situation ; and with 
regard to tubercle, Rokitansky affirms that it sometimes occurs inde- 
pendently of uterine deposits, or in a condition of higher development. 
He describes it as being presented to us in the form of tubercular infil- 
tration, and complete disorganization of the mucous membrane, which 
is converted into a soft purulent layer of cheesy, friable matter, that 
chokes up the passage, and causes the tube to be more or less swollen 
and tortuous, and hard to the touch. 



CHAPTER XL. 

THE OVARIES. 

The pathology of the ovaries, important as are the questions involved 
in it, is still very imperfect, owing to their site, and to the absence of 
any secretion, the analysis of which may indicate their condition; their 
examination by the means at our command being often neglected from 
motives of delicacy, their morbid conditions are frequently not detected 
until an advanced stage. Many of the diseases in which the functional 
derangements of the system are referred to a local condition of the 
generative organs, are exclusively attributed to lesions of the uterus, 
from a definite physical examination being more practicable, and the 
primary derangement of the ovaries is overlooked. The stimulus which 
puberty gives to the development of these organs and their proper func- 
tions, is also the starting-point for their morbid conditions ; before this 
time they are in a dormant state, and, except in connection with general 
diseased processes affecting the abdominal viscera, or the system at large, 
they rarely present any palpable lesions. It is, however, necessary to 
bear in mind that the ovaries may, and often are, sympathetically 
affected during the peritonitis of childhood, a disease of frequent occur- 
rence. Boivin and Dugks 1 consider these inflammations a cause of 
obliteration of the Graafian vesicles, and a consequent source of sterility, 
which they may also induce by changing the position, or altering the 
relation, of the ovary and its Fallopian tube. Even after the period of 
puberty, the ovaries are exempt from many of those sources of irritation 
to which the uterus, from its exposure to direct injury, to contact with 
morbid secretion, and from the entire revolution in its functions which 
it suffers during and after pregnancy, would appear to be exposed; yet 
it has been shown by Parent Duch&telet and others, that these local 
influences are not as powerful as would be assumed d priori ; since 
ovarian disease has been found peculiarly prevalent among prostitutes, 
and frequently unaccompanied by any lesion of the external organs of 
generation. Of the frequent physiological congestion of the ovaries, a 
doubt can scarcely be entertained by any one who has watched the 
relation these organs bear to menstruation, independently of the direct 
observation of Dr. Letheby, Dr. Lee, and others, of the presence of an 
ovum in the Fallopian tube, and of the rupture of a Graafian vesicle in 
females who happened to die suddenly during the menstrual period. 
The almost uniform effect of a morbid arrest of the catamenia, by ca- 
tarrhal or similar influences, in producing symptoms of an inflammatory 

1 Traits Pratique des Maladies de l'Uterus, &c. vol. ii. p. 509. 



OVARIAN DROPSY. 645 

process in the ovaries, further corroborates this view. In the dead bodies, 
ovarian inflammation is rarely met with in an isolated form, but associ- 
ated with affections of the uterus, or its appendages. It does, however, 
occur as an idiopathic disease. In the congestive stage, the organ is 
more or less gorged with blood, even amounting to extravasation or 
apoplexy, enlarged and softened. It is to the partial absorption of such 
extravasations, and the accompanying changes, that we must attribute 
the so-called false corpora lutea. These differ from the true corpus 
luteum in the yellow matter, from which the name is derived, being 
inclosed within the Graafian vesicle, while in the latter, the deposit is 
effected externally to the vesicle, which in the recent state retains a 
cavity, that only shrinks, and is obliterated after the lapse of several 
months. 

It is in the corpora lutea of various animals that Zwicky first dis- 
covered and described certain varieties of organic crystals, since termed, 
by Virchow, hasmatoidin crystals, and shown, by him and other observers, 1 
to be produced in the blood of all animals and of man, in extravasations 
occurring within the body, or when treated in a certain manner after 
its removal. Inflammation of the ovaries may, independently of the 
puerperal state, lead to suppuration. An observation of Dr. Ashwell 2 
to this effect corroborates the statement of Rokitansky that, in this case, 
it is always limited to the follicular structures. The latter describes the 
coats of the follicles reddened and softened, and the cavity filled with 
an opaque, flocculent, sanguineous, or puriform material, which neces- 
sarily destroys the germ. 



OVARIAN DROPSY. 

It is to the sequelae of acute inflammation, or to the effects of a chronic 
phlogistic process, that we must attribute a large number of those morbid 
states of the ovaries, which form so considerable an item in the list of 
female diseases. Both the general pathology of the organ and the etiology 
of the individual cases justify this remark. We particularly allude to 
that class of affections known under the generic term of ovarian dropsy; 
a disease that is characterized by the formation of cysts, which in this 
organ exhibit a peculiar tendency to extravagant development, a circum- 
stance that may be attributed to the reproductive powers of the part, to 
the proportionally copious supply of blood, and to the entire exemption 
from all pressure or restraint which might limit their growth. 3 It is a 
disease which affects married women in a much higher ratio than single 
females. Mr. Safford Lee has collected and analyzed 136 cases, with 
a view to determining this point statistically, and finds that only thirty- 
seven were single, while ninety-nine were married women or widows. 
This fact seems to prove that the ovary undergoes a different excitement 

1 See an article in the British and Foreign Review, October, 1853, on Albuminous Crys- 
tallization, by E. H. Sieveking. 

2 On the Diseases of Women, p. 625. 

3 See Dr. Hodgkin's Lectures on the Morbid Anatomy of Serous and Mucous Mem- 
branes, vol. i. p. 242. 



m 



OVARIAN DROPSY. 



in the discharge of an ovum resulting from impregnation, than when 
this takes place simply as a concomitant of the catamenia. Another 
point established by the same author has reference to the age at which 
women are most liable to the affection. He shows that it is erroneous 
to assume dropsy of the ovary to prevail during the decline of life. 
One hundred and forty cases are distributed in the following manner: — 



From 15 to 20. 


20 to 30. 


30 to 40. 


40 to 50. 


50 to 60. 


60 to 70. 


70 to 80. 


Age not 
specified. 


3 


37 


45 


26 


19 


3 


2 


5 



This, as well as the preceding numbers, satisfactorily proves that 
there is an intimate connection between the morbid impetus inducing 
the disease and the reproductive process. In the second table, we also 
find a feature which distinguishes the former from the cancerous dia- 
thesis, for while the climax of ovarian dropsy is between the thirtieth 
and fortieth, that of carcinoma is demonstrated to be between the for- 
tieth and fiftieth years. Dr. Hodgkin is of opinion that there is an 
hereditary predisposition in some females to the production of ovarian 
cysts, but that we rarely find a simultaneous affection of the same kind 
in other parts of the body. It is not often that we see both ovaries 
affected; the right, according to the statistics of Mr. Lee, being the 
more frequent seat of the malady ; of ninety-three cases, collected by 
him, fifty occurred on the right, thirty-five on the left side, and eight 
on both sides. 

Ovarian dropsy presents various forms characterized by features well 
known to the practitioner, and equally distinct in their pathological 
relations. The cyst-growths which constitute the disease are simple or 
unilocular, compound or multilocular, and complicated or cancerous. 

Simple cysts are globular sacs, containing fluid, formed of an envelop 
with a single undivided cavity, and inclosed in the ovary or external to 
it. They are solitary or numerous, and we occasionally find an ovary 
scarcely exceeding the normal size, in which the stroma has disappeared, 
and is replaced by small cysts of this description, varying in size from 
a pin's head to a pea. In this case they are, probably, always the re- 
sult of a distension of the Graafian vesicles by a morbid increase of 
their contents, which, at the same time, necessarily undergo a change 
in their constitution. The number of the Graafian follicles is stated 
to amount to about fifteen; where the number of cysts considerably 
exceed this proportion, we may perhaps be justified in attributing them 
to an independent germinative power, though it suggests itself, that if 
the view be correct that an ovum is discharged at each menstrual period, 
either anatomists err in their statement, or another view is requisite to 
account for their successive formation; upon this theory, there would be 
no unfair assumption of an identity between the processes. Another 
argument in favor of the doctrine that the simple cysts result from an 
hypertrophy of the Graafian vesicles may be derived from the well- 
known fact that they are often found to contain evidences of morbid 
germination, in the shape of hair, teeth, and bones, not referable to 
impregnation. They may attain a very considerable size, so as to hold 



OVARIAN DROPSY. 647 

several gallons of fluid; the envelop then presents a leathery appear- 
ance, varying in thickness from a quarter of a line to several inches, 
and their fluctuation becomes a very manifest diagnostic sign. A speci- 
men of this kind is the preparation marked X 16, in the Museum of 
St. George's Hospital, which was connected with the right ovary, and 
in the parietes of which several well-developed teeth are inserted, 1 as 
into the alveoli of the jaws, their crowns projecting freely into the cavity. 
They more commonly, however, do not reach this magnitude, are of very 

Fig. 330. 




V: 

Incipient cyst-formation. The ovary is represented of the normal size. 

slow growth, and resist medicinal agents. The fluid they contain varies 
as much in color and constitution as in quantity: it is a clear, limpid, 
straw-colored, highly albuminous fluid ; or it presents a viscid, glairy, 
more or less opaque character; or we find it of a coffee color, or greenish, 
with a large quantity of oily matter floating on the surface. In the 
latter cases, the microscope demonstrates the presence of blood-corpus- 
cles and cholesterin plates. During life, paracentesis often is followed 
by discharges of several kinds of fluid at different periods of the opera- 
tion; this can only occur in consequence of our having to deal with a 
case in which there are several cysts, which are penetrated by the trocar 
or give way spontaneously. 

Simple cysts, that form on the surface, like those produced in the 
vicinity, may be altogether a new formation, though it is to be remem- 
bered that in the advanced stage of development the relation of the 
cyst to the ovary is considerably altered from what it presents at earlier 
periods. Pedunculated cysts are always small in size, possess thin coats, 
and their contents are transparent. They evidently possess a character 
distinct from those previously spoken of. 

Multilocular cysts are growths possessed of a power of self-multiplica- 
tion, which is as surprising in its features as it is characteristic of the 
heterologous source of their development. They also form more or less 
circular tumors, occasionally nodulated on the surface from the projec- 
tion of some of the contained secondary cysts. The opportunity is 

1 We do not deny the occasional anomalous formation of bone, teeth, and hair, in cysts 
contained in other situations besides the ovary, but the prevalence of this phenomenon in 
the latter indicates a peculiar tendency. 



648 OVARIAN DROPSY. 

rarely afforded of examining the disease in its early stages, as it does 
not prove fatal until it has attained an enormous size ; still, the various 
appearances it presents are reducible to three classes, which Dr. Hodg- 
kin was the first satisfactorily to demonstrate. In the first variety, we 
find that incision into the enlarged ovary, instead of exposing a single 
cavity, displays numerous chambers, each filled with smaller cysts, 
which, in their interior, commonly exhibit a tertiary formation of the 
same kind. The septa are probably the result of rupture from over- 
distension of cysts in the earlier stages. The cysts are permanently 
attached to their respective matrix, bloodvessels ramify freely over 
them, and there is a continuous and uniform epithelial investment. 
Their contents are commonly of a viscid, glairy, albuminous character, 
varying much in color, yellow, green, blue, red, and grumous, or trans- 
parent, probably owing to accidental local irritation and the admixture 
of the inflammatory products. The microscopic appearances of the 

Fig. 331. 




A multilocular ovarian cyst, removed from a female, ast. 29, during life, by Mr. J. B. Brown. Septa form 
larger compartments, in which thei'e is a secondary and tertiary growth of cysts. The tumour weighed 11 
lbs. 3 oz. 

contents will vary accordingly ; but we have found what may be con- 
sidered the genuine cyst-products to consist of granular cells of circular 
form with well-defined outlines, conveying the impression that the fluid 
itself was a germinating nidus. The celloid particles vary in size from 
toSou" to to? oo °f an i n °h; they float in a fluid blastema, are colorless, 
and contain one or more granular nuclei; there are also corpuscles that 
are identical with blood-corpuscles, though not contained in vascular 
channels. The walls of the cyst consist of delicate fibroid tissue, 
covered by a layer of cells, and delicate cells may be seen imbedded in 
the tissue. 

The second variety of compound cysts is characterized by the develop- 
ment of clusters of pedunculated cysts from the inner surface of the 
primary sac. " It sometimes happens that the number of cysts forming 
the cluster is so great in proportion to the space they occupy, that, like 
trees too thickly planted, they interfere with each other's growth ; their 



FIBROUS GROWTHS. 649 

development is more or less limited to an increase of dimension in length, 
yet, as their free extremities are allowed to diverge, we sometimes find 
the slender peduncle gradually dilating into a pyriform cyst, at other 
times the dilatation does not take place till near the extremity of the 
peduncle, and it thus produces a cyst more nearly resembling a grape 
or currant." 1 The pedunculated cysts may grow directly from the matrix 
and form a common footstalk; sometimes they are very vascular, at 
others but feebly organized, and may become entirely deprived of vitality, 
in which case they prove a frequent source of irritation to the contain- 
ing cyst. This induces inflammatory secretions of an inorganizable kind, 
of a thick, yellow, grumous appearance. 

In the third variety, Dr. Hodgkin describes the secondary cysts as 
distinguished by the breadth of their basis and by a flattened form ; they 
are collected in clusters upon the external cyst, and produce a circum- 
scribed and more or less considerable thickening of the parietes. The 
tertiary cysts found within them present the same broad sessile character, 
and both contain, "sometimes a mucous, at others a serous," secretion. 
We should be inclined to class the first and third forms together as mere 
accidental variations of the same type. This remark almost applies to 
the three varieties, since the fact of their being frequently combined 
in the same ovary indicates the same fundamental morbid tendency and 
impulse. 

Rokitansky describes a form of compound ovarian cysts, which he 
regards as identical with alveolar cancer, though peculiar to the ovary. 
He states it to be an accumulation of fibrous sacs, containing a glutinous 
matter, which diminish from the circumference towards the interior, and 
especially towards the base of the morbid growth, so that this presents 
a condensed alveolar mass, of a distinctly malignant character. 

The complicated form of ovarian dropsy is that in which the cyst for- 
mation is, as it were, engrafted upon, or associated with, other diseased 
states of the organ, such as hypertrophy, fibrous tumors, or carcinoma- 
tous growths ; this is a feature which becomes of practical importance 
in reference to the influence of curative means, and the question of ex- 
tirpation. The latter is also closely affected by those secondary inflam- 
matory processes which the enlarging ovary is apt to induce ; peritonitis 
very commonly results, by which adhesions of the ovary to the surround- 
ing tissues are effected ; and while the pressure of the enlarging tumor 
materially interferes with the functions of the surrounding viscera, the 
bladder, the intestines, the kidneys, the diaphragm, and respiratory 
organs, it also exerts a dynamical effect in producing ulceration and 
perforation of the colon or bladder. In the earlier stages, ovarian 
tumors prove serious impediments to parturition. 



FIBROUS GROWTHS. 

These affect the ovaries as primary formations evolved in the sub- 
stance of the organ and closely resembling those which we have de- 
scribed as occurring in the uterus; or, as a secondary development, 

1 Hodgkin, 1. c. p. 233. 



650 THE MAMMJ. 

accompanying the evolution of ovarian cysts. The fibrous tumor is 
developed in the tissue of the ovary, presents a globular form, and 
though of slow growth may attain an enormous size. The largest one 
on record occurred in the practice of Dr. Simpson, and weighed fifty- 
six pounds. The outline of the tumor is well defined ; it is commonly 
supposed to be very scantily provided with bloodvessels, against which 
the appearance of some injected specimens, contained in the Museum 
of St. George's Hospital, appears to militate; one (No. 145), that oc- 
cupies the greater part of the organ, actually exhibits greater vas- 
cularity than the surrounding normal texture. Like the tumors of the 
same class in the uterus, they are here also found to give rise to small 
cysts in their interior. Fibrous tumors of the ovary occasionally exhi- 
bit a tendency to so-called ossification, which consists in the conversion 
of a portion of its tissue into calcareous matter. 

Tubercle occurs so rarely in the ovaries that the majority of morbid 
anatomists are either silent on the subject, or even, as, for instance, 
Rokitansky, deny its development in this locality altogether. Louis, 
however, established the fact of these organs not being exempt, as he 
has observed a small quantity of tuberculous matter in two instances. 

Malignant disease assumes several forms in the ovary, and though 
its frequency has been exaggerated by Boivin and Duges, 1 who state 
that it is more common than carcinoma of the female breast, and only 
less so than that of the uterus, all modern pathologists are agreed as to 
its being by no means a rare affection. It appears as scirrhus, ence- 
phaloid, haematoid, melanotic, and alveolar cancer, either as an isolated 
growth, or in the infiltrated form. " Cancerous matter,'' to use Dr. 
Walshe's words, " especially the encephaloid, is more commonly dis- 
covered in the ovary as an addition to some other morbid formation 
than as the sole disease of the organ; multilocular cystoid productions 
are those to which it is most frequently superadded ; in much more rare 
instances a multilocular cyst pre-exists. Under such circumstances, the 
cancerous deposition goes on in connection with the walls of the cysts, 
and exhibits all the varieties of pedunculated and sessile forms. When 
thus formed in the walls of cysts, encephaloid frequently coexists with 
fibrous, cartilaginiform, calcareous, or ossiform infiltration of those walls." 

Ovarian cancer runs a rapid course ; it is generally limited to the 
ovary of one side, and, as it extends, is liable to induce inflammation of 
the surrounding parts, causing adhesions, which will fix the tumor in 
the pelvis, or attach it to the viscera, occupying a higher level accord- 
ing to the period at which they form. Cancer occurs more frequently 
at an earlier period of life in this organ than in the uterus ; Dr. Walshe 
has found forty-one years the average age at death ; but it has been 
met with even before puberty. 



THE MAMM^. 

Diseases of the mammae are essentially diseases of the adult female — 
we must not, however, overlook those cases which occur in the male sex 
and in infant life. 

1 Traite Pratique, &c. vol. ii. p. 554. 



THE MAMMJE. 651 

At birth, the breasts of infants of either sex are very commonly 
swollen and somewhat indurated; they contain a whitish serum, which 
induces nurses to employ friction for the purpose, as it is termed, of 
rubbing the milk away. The result of this proceeding is frequently to 
induce inflammation and abscess in the part; which, however, may also 
occur spontaneously, and even become chronic. At the period of pu- 
berty, the gradual development of the glands in the female serves to 
mark their ultimate function, and to define the character of the sex. 
It is now that irregular evolution is exhibited as an atrophic, or an hy- 
pertrophic condition of the whole gland, or of the nipple only. The 
proper tissue of the gland, as well as the surrounding fat, and cellular 
and cutaneous textures, may be separately or coincidentally involved in 
each case. The hypertrophy sometimes attains a very considerable 
size in unmarried females, and appears to be an indication of a gene- 
rally precocious tendency. Commonly, both breasts are affected; but 
occasionally, one is inordinately developed. A temporary enlargement 
of the gland very commonly accompanies menstruation ; it may occur 
periodically, even long after the cessation of this function, as in an old 
lady of eighty-five, who was under our care, and who was subject to 
this phenomenon regularly every month. A permanently hypertrophic 
state is induced by lactation ; the period which directly or indirectly 
gives rise to many of those morbid conditions to which the gland is 
liable. Inflammation is one that in the acute form is almost limited to 
this period. It produces congestion in one or more parts, accompanied 
by swelling, interstitial effusion, condensation, and finally, if the disease 
be not arrested, suppuration and abscesses. The glandular texture 
itself, or more frequently, the intercellular tissue, is the primary seat of 
lesion : the lacteal secretion frequently continuing during the inflamma- 
tory process, and even after a chronic state of induration and enlarge- 
ment has been established, which has led to the removal of the organ. 
When the inflammation is confined to the true gland structure, the re- 
sulting tumefaction is irregular and lobulated, and deeper seated than 
when the interstitial or cutaneous tissues are mainly involved. When 
suppuration is established, it may be limited to one spot by adhesive 
inflammation, and the abscess be evacuated by pointing, as it usually 
does, near the nipple ; or burrowing sinuses form, which may extend to 
a considerable distance. During lactation, large accumulations of milk 
frequently distend the entire system of ducts, or a single portion ; in 
the latter case, a fluctuating tumor may result, which will scarcely dis- 
appear without surgical interference. It is stated, that as much as ten 
pints of milk have been evacuated from a swelling of this description. 
It appears to be generally owing to an atonic state of the mammary 
ducts, similar to the condition of the efferent channels in the nipple, 
causing a non-retention of the secretion. The lactiferous tubes are oc- 
casionally found to contain sebaceous-looking matter, phosphatic con- 
cretions, and other products, which have been attributed to the effects 
of chronic inflammation (College of Surgeons, Nos. 2,743, 2,744, 2,747, 
2,748); but unless there is a coincident change in the coats of the 
ducts, it is probable that these matters are the residue of an effusion of 



652 



THE MAMMJ, 



milk, which has been long retained, and in which a partial absorption 
has taken place. 

Adventitious growths are very frequently met with in the mammary 
glands, presenting the characters of benignant and malignant formations, 
and deserving careful attention on account of the pathological as well as 
the practical interest that attaches to them. Much difficulty is often pre- 
sented in determining the diagnosis during life, and it is only since the 
microscope has been brought to bear upon an analysis of these mammary 
affections that a clear light has been shed upon them, which has already 
borne fruits in practice. 

Encysted tumors present two great classes, those dependent upon an 
expansion of the ducts, and those resulting from a new growth in the 
fibro-cellular or adipose tissue ; a state of things closely analogous to 
what we meet with in the kidney. To the former we have already 
alluded. The latter occurs as an isolated globular or oval and more or 
less movable cyst, or there are numerous growths of this, kind, varying 
in size from a pin's head to a hen's egg. The inner surface is smooth, 

Fig. 332. 




or it presents a broad-based lobulated cauliflower-like growth or warty 
excrescences, and the substance of the surrounding gland is indurated 
and atrophied. These cysts may also occasion a retraction of the nipple, 
a point of practical importance, as this is often looked upon as pathogno- 
monic of cancer. The transverse section exhibits a double sheath, one 
proper to the cyst, the other the result of condensation of the adjoining 
textures. The contents of the cyst may be fluid or solid ; the former 
presenting either a limpid and opalescent, non-albuminous character, or 
a grumous, brownish, more or less sanguineous appearance, in which case 
it is highly albuminous ; the latter approaching the character of fibroid 
deposits, being composed of a pale, firm, compact substance, traversed by 
undulating fibrous lines, which imperfectly divide it into lobes of various 
sizes or shapes. These cysts have been termed cysto-sarcoma, or sero- 
cystic growths, by Sir Astley Cooper, and Sir Benjamin Brodie. Mr. 
Birkett 1 has found that they contain imperfect gland-tissue, and that the 

1 The Diseases of the Breast, and their Treatment. London, 1850, p. 64, seqq. 



THE MAMMiE. 653 

intra-cystic growth is invested by a reflection of epithelium from the 
cyst-wall. His views on the subject may be thus expressed : Certain 
collections of a plastic fluid take place in the areolar tissue of the gland, 
a closed cavity is formed, lined with tessellated epithelium, and the intra- 
cystic growths, being within the sphere of nutrition of the mammary 
gland, present more or less resemblance to the latter; hence, they may 
be regarded as imperfectly-developed gland-tissue, which offers no analogy 
to carcinoma, either in its local appearance or in its effect upon the sys- 

Fig. 334. 





Example of cysto-sarcoma, from the breast. At a, the Cysto-sarcoma simplex, from the neigh- 
cysts many ; distinctly lined by a secreting membrane, and borhood of the mamma. One large cyst, 
filled with a glairy fluid. At b, a section made on another a. b. The solid part of the tumor; a sim- 
plane ; cysts less numerous. pie stroma. 

tem. While we would not altogether deny the conclusions at which Mr. 
Birkett has arrived on this point, we should be disposed to question the 
secondary formation of gland-tissue in a previously-existing cyst, and, 
where we meet with an encysted growth of this kind, include it under 
what he has appropriately termed lobular imperfect hypertrophy (1. c. 
p. 124) ; for although the tumors of this description ordinarily remain 
in connection with the proper gland-tissue, they sometimes appear to be 
altogether isolated, and a capsule of condensed cell-tissue easily simu- 
lates a genuine cyst. 

In a small tumor of this description, removed from the breast by ope- 
ration, on the supposition of its scirrhoid nature and of its being uncon- 
nected with the gland, which we had an opportunity of examining, the 
microscope revealed well-marked ducts and lobules, in no essential feature 
differing from ordinary mammary tissue. We have since repeatedly 
examined the structure of mammary tumors, which were regarded as 
malignant, and found them to consist of follicular structure filled with 
epithelial growth. Mr. Birkett describes this form of tumor as presenting 
to the naked eye a granular appearance of a white, rosy, or red color, 
dependent in a measure upon the time it has been exposed to the air; it 
is lobulated, divisible into the most minute lobules, attached by a pro- 
longation to the breast, and invested by a fibro-cellular envelop continu- 
ous with the proper fascia of the gland. The lobules are connected by 
common areolar tissue, and the growths vary in size from that of a marble 
to that of a child's head. 



65± 



THE MAMMJ1. 



The genuine hydatid cyst, containing the echinococcus, occurs in the 
female breast, and may be recognized by its well-known features. The 
tumor itself grows imperceptibly, causes no annoyance to the patient, 




Lobular hypertrophy of mamma. A. Section, showing the entrance of duct. b. Cross section, 
resembling cystic disease. 

is firm to the touch, and contains clear fluid, in which the microscope 
detects the tentacula of the echinococcus, the animalcule itself being 
attached to the internal wall of the cavity. 

Many so-called fibrous tumors of the breast are to be considered as 



Fig. 336. 



Fig. 337. 



Fig. 338. 




This series of diagrams represents microscopic sections of a simple tumor removed by operation from the 
female breast; consisting mainly of hypertrophy of the fibrous structure of the gland, with enlargement of 
the included ducts and their epithelial liniugs. c. Section of the epithelium from one of the tubes. &. Group 
of epithelial cells from the same. a. The same after the addition of acetic acid. — Bennett. 



THE MAMMil. 



655 



Mr. Birkett has demonstrated, as belonging to the same class as that 
just considered ; and though he does not deny the existence of an hyper- 
trophied condition of the fibrous tissue, he has found the elementary 
gland tissue to preponderate in all the cases called fibrous which he has 
examined. This accords with the observations of other pathologists, 
who either deny the occurrence of fibrous, cartilaginous, and osseous 
tissues in the mamma, or adduce only doubtful or solitary instances. 
Sir Astley Cooper removed a tumor from a young woman, aged thirty- 
two, the larger portion of which had the appearance of the cartilage 
supplying the place of bone in the young subject ; the remainder being 
ossified. Professor Miiller states that he met with a case of enchondroma 
in the organ. 

Tubercle has not been met with in the mamma. Cancer affects the 
mamma more frequently than any organ of the body ; it obeys the same 
laws as to the period of life in which it most flourishes as we have traced 
when speaking of uterine cancer. The analysis of one hundred and 
forty-seven cases 1 exhibits a marked preponderance in the fifth decen- 
nium of life, as the following table, given by Mr. Birkett, shows : — 



rom 1 to 10 years 


1 case. 


From 50 to 60 years 


. 29 cases 


" 10 " 20 " 


3 cases. 


" 60 " 70 " 


. 10 « 


" 20 " 30 " 


. 11 « 


" 70 " 80 " 


. 2 » 


" 30 " 40 " 


. 32 " 


" 80 " 90 " 


. 7 " 


" 40 » 50 " 


. 51 " 


" 90 "100 " 


. 1 " 



Of one hundred and sixteen cases, seventy-nine were married women, 
and thirty-seven single; of fifty-five married women, forty-seven were 
prolific, many of them having borne several children, and only eight 
were sterile. Sir A. Cooper knew a woman with this disease who was 
pregnant seventeen times. These numbers must not, however, be taken 
as absolute indications, but only approximatively ; it is to be remembered 
that the proclivity to cancer being greatest between forty and fifty, the 
correct ratio of married and unmarried females could only be calculated 
by knowing the total numbers of these two classes. Dr. Walshe shows 
that the left side is more frequently affected than the right; of one 
hundred and two cases, fifty-nine were limited to the left, thirty-nine to 
the right breast, and in four only were both implicated. 

All the varieties of carcinoma have been met with in the breast; scir- 
rhus is, however, by far the most frequent form in which it occurs 
primarily ; the encephaloid variety may be primary, but is more com- 
monly engrafted upon the former; the colloid form is the most rare. When 
associated with other cancers, that of the mamma is stated by Dr. Walshe 
to be invariably primary, except in those rare instances when the disease 
spreads from the lymphatic glands or superjacent skin. 

Scirrhus occurs in the form of a hard, lobulated tumor, imbedded in 
the adipose tissue of the gland, causing adhesion to the skin, and retrac- 
tion of the nipple; at first, somewhat movable, but soon becoming firmly 
adherent to the subjacent parts, and involving more or less of the gland- 
tissue, the thoracic muscles, and the adjoining glands. Instead, however, 
of occurring as an isolated tumor in the first instance, it may, from the 



1 Birkett, 1. c. p. 218, 



656 



THE MAMMiE. 



commencement, appear as an infiltration of the various structures of the 
part ; it will then be ill-defined, sending out branches into the adjacent 
tk-ues, and in that case involving in its mass the lacteal tubes and 



Fig. 339. 



Fig. 340. 





Carcinoma of the breast, bisected. The figure of 
the tumor, with its effect on the gland and nipple 
shown. 



ML 

Carcinoma, secondary. An example of the nu- 
merous nodulated tumors, which often form in the 
cicatrix of the former growth. One is ulcerated in the 
site of the mammilla. 



lymphatics. These become contracted and flattened into many bands, 
which give a peculiar appearance to this form of mammary cancer. Dr. 
Walshe has repeatedly seen similar structures when cut across, exhibiting 
an obvious bore, and he has succeeded in detecting the character in some 



Fia;. 341. 




Section of a large, hard, cancerous tumor, from a woman aet. 60, imbedded in the breast, exhibiting a pale 
dull-grayish basis, shaded with light pink, and intersected in every direction by short wavy lines, like bundles 
of white fibres, which mingle together in a close irregular network. This fibrous structure is most distinct 
about the centre of the mass, its exterior appears more homogeneous. *. The retracted nipple. — St. Barthol. 
Museum, xxxiv. 14. 



seen lengthwise ; but he has never noticed these forms except in mam- 
mary cancer. Scirrhus is not at first accompanied by pain ; hence its 
existence is often accidentally discovered when it has already reached 
the size of a marble or a pigeon's egg 



Ulceration of the skin, in the 



THE MALE MAMMA. 657 

vicinity of the nipple, supervenes ; the edges of the sore are raised, 
everted, and puckered ; a purulent, ichorous fluid is secreted, from a 
bluish-red, eroded surface, offering a faint and fetid odor; bleeding often 
ensues, and the patient sinks from exhaustion. The amount of pain 
suffered appears to depend upon the nervous constitution of the indi- 
vidual, since it does not present any uniform proportion to the extent 
of the primary affection, or of the secondary ulceration ; one of the 
largest scirrhous tumors that has fallen under our observation, followed 
by extensive ulceration and frequent hemorrhage, gave rise to no bodily 
pain from first to last ; while it is a matter of daily observation that 
intense lacerating pains in the breast and arm of the affected side accom- 
pany tumors whose extent does not warrant the supposition that any 
direct irritation of the nerves can take place. Scirrhus generally attains 
the size of an orange or a man's fist, and more ; it passes through its 
various stages with more or less rapidity, averaging about three years 
altogether; the ulcerative stage once commenced, the powers of the 
system are soon broken. Sir A. Cooper states that the period of growth 
lasts from two to three years, and that, after it has attained its full de- 
velopment, the time in which it proves fatal varies from six months to 
two years. The older the individual at the time at which it first appears, 
the slower its subsequent growth ; hence, the practical rule followed by 
Sir A. Cooper, that, in advanced life, surgical interference is neither 
humane nor scientific. The axillary lymphatic glands are commonly 
swollen, hard, and infiltrated with the same carcinomatous product as 
the mamma; their affection appears to be coincident with the implication 
of the skin at the primary seat of injury. The pectoral muscles, the 
ribs and costal cartilages, are also found secondarily involved to a greater 
or less extent; a secondary affection of the pleura and the lung is not 
unfrequent. Towards the termination of the disease, from direct inter- 
ference w T ith the venous circulation, oedema of the extremity of the 
affected side is liable to supervene. 

The encephaloid form of the disease occurs earlier in life, and gene- 
rally runs a more rapid course than the one just considered. It is much 
less frequent, and, though sometimes primary, is commonly met with as 
a complication of scirrhus. Moreover, it presents a less defined mar- 
gin ; according to Sir Astley Cooper, it is difficult to say where the 
diseased structure terminates, and where the healthy structure com- 
mences ; the base of the tumor is, therefore, diffused among the healthy 
cellular membrane, or other parts, where it shall happen to be situated; 
another diagnostic sign, as pointed out by Sir A. Cooper, is that the 
disease may advance even to suppuration and ulceration without the 
glands of the axilla becoming at all affected. 



THE MALE MAMMA. 

The male breast is occasionally the seat of non-malignant and malig- 
nant growths. We have ourselves met with an instance, in a gentleman 
aged twenty-one, of the former, which, to the touch, closely resembled 
one of hvpertrophv of the mammary gland ; it was of the size of a shil- 

42 



658 THE MALE MAMMA. 

ling ; felt semi-cartilaginous, as if composed of lacteal ducts, and was 
adherent to the skin of the nipple. The individual had perceived it six 
■weeks before applying for advice ; it gave no pain, and four months 
later we were informed that it had almost disappeared without any 
active treatment being pursued. This is in accordance with the struc- 
ture of the male mamma, which Sir A. Cooper has shown to resemble 
the female gland, though in a rudimentary state. Nor could we other- 
wise account for the well-authenticated cases of the secretion of milk 
by men. Mr. Birkett gives delineations, showing the male gland to 
have all the essential elements requisite for the performance of the 
function. Mr. Stanley 1 relates the case of a man, aged forty-five, who 
was affected with cancer of the right humerus, secondary to cancer of 
the right breast. Cruveilhier states that three cases have come under 
his observation, one of which is delineated in his atlas. 2 In the College 
of Surgeons (prep. 2,791), there is the section of the breast of a man 
with a very vascular ulcer, five inches in diameter, probably originating 
in a lens-shaped, hard, cancerous tumor, or a degeneration of the skin 
and mammary gland. The monographs on diseases of the mamma also 
contain records of simple cysts, compound cysts, and encysted tumors, 
occurring in the male breast ; but they belong to the mere curiosities of 
medical experience. 

1 A Treatise on the Diseases of the Bones, by Edward Stanley, F. U.S., 1849, p. 255. 

2 Anatomie Pathol. Livr. xsiv. 



THE PATHOLOGICAL ANATOMY OF THE 

JOINTS. 



CHAPTER XLI. 

DISEASES OF THE JOINTS. 

Malformations. — In cases of defective development, some joints may 
be quite absent, the bones may be united by congenital anchylosis ; or, 
in a less degree of imperfection, they may be incompletely formed, the 
ligaments sometimes being partly or altogether wanting even when the 
rudimentary extremity of the bone is covered with cartilage. On the 
other hand, supernumerary joints exist, both when the number of bones 
is natural and when it is excessive. 

Inflammation of the Synovial Membrane. — This may arise as a pri- 
mary disease spontaneously, from cold, from injuries, from localization 
of the rheumatic poison, or from that of syphilis, or gonorrhoea. It 
also occurs as a secondary affection, excited by disease of the cartilage, 
or of the subjacent osseous tissue. It may be acute in various degrees, 
or chronic. It is rare in young children, less so about the age of pu- 
berty, and very frequent in adults. Before we describe the morbid 
changes, we must advert to two points in the anatomical arrangement 
of this membrane, which are of much importance. The synovial are 
commonly, and no doubt justly, classed with the serous membranes, and 
are described to form shut sacs, just as these are. Dissection, how- 
ever, fails to trace the membrane over the free surface of the cartilages, 
and microscopic examination confirms its absence, except in the foetus. 
In these unused joints the cartilaginous surface is found quite smooth 
and even, and covered by a layer of delicate epithelial scales, such as 
line the surface of the synovial membrane when it passes over the liga- 
ments. In the articulations, however, of adults, not only is the epithelial 
layer absent, but the surface of the cartilage is slightly irregular, as if 
somewhat worn. Our own examinations have convinced us of the general 
correctness of these statements, given by Dr. Todd and Mr. Bowman, 
but we must also mention that another high authority, Mr. Toynbee, is 
of a different opinion, and believes that he can demonstrate the existence 
of the synovial membrane in the adult, by detaching an exceedingly 
delicate layer from the cartilage, which, he states, does not contain any 
of the cartilage-cells. This, we think, is a film of the cartilage itself, 



660 INFLAMMATION OF THE SYNOVIAL MEMBRANE. 

only so thin that it cannot include the cells. The other point we wish 
to notice is the existence of a set of remarkable vascular processes, 
covered by a delicate epithelium, upon the free projecting margin of 
those synovial folds which advance into the cavities of joints. Mr. 
Rainey, by his discovery of these, has confirmed the anticipation of 
Clopton Havers, that those synovial folds fulfil, in some measure, the 
function of glands, being particularly concerned in the formation of the 
synovia. It is, we are convinced, from these vascular processes that 
bloodvessels first enter the false membrane formed by exuded lymph. 

The results of acute synovitis are the following : More or less injec- 
tion of the vessels, which in one instance, related by Sir B. Brodie, were 
so distended with blood that, " throughout the whole of its internal sur- 
face, except where it covered the cartilages, the synovial membrane was 
of a dark red color," like the conjunctiva in acute ophthalmia. Effusion 
of serous fluid, which may be so great as to lead one to suppose that the 
sac is filled with solid matter. Effusion of lymph, forming flakes all over 
the synovial surface, and not upon the cartilages. In severe cases sup- 
puration may occur. If the disease advance unchecked, ulceration of 
the cartilages is very prone to occur ; the exuded lymph then forms 
villous or fringed processes, which are in contact with the ulcerating 
part of the cartilage, and probably both promote the destructive pro- 
cess, and aid in removing, by absorption, the disintegrating tissue. We 
shall return to this point again under the head of ulceration of cartilage. 
Under judicious treatment, the whole of the fluid will be reabsorbed, and 
the joint return to a perfectly healthy state. If, however, much solid 
exudation is present, its absorption will be more difficult, and some 
amount of swelling and stiffness of the part will still remain. 

"Chronic synovitis," Sir B. Brodie says, " causes an increased secre- 
tion of fluid, but does not in general terminate in the effusion of coagu- 
lable lymph, or in thickening of the inflamed membrane." Fibrinous 
matter is, however, if the disease continue long, or often recur, effused 
either on the inside or outside of the synovial membrane, and becoming 
gradually organized into a fibroid tissue, thickens its substance and 
renders it sometimes firm and gristly. A preparation in the Museum 
of St. George's Hospital, shows the synovial membrane of the knee-joint 
so altered in this way as to be nearly an inch thick. It may be difficult, 
if not impossible, to detect the presence of fluid in the cavity of a joint 
which is in this state. Serous effusion, to a considerable amount, some- 
times takes place in the synovial sac, without any manifest inflamma- 
tion. The affection is analogous to hydrocele, and belongs to the class 
of passive dropsies. Its causes are generally obscure. When abscess 
occurs in a joint, the pus is commonly mixed with more or less of syno- 
vial fluid, and flakes of lymph, and is sometimes quite of a sea-green 
color. There is, also, sometimes, suppuration outside the joint, the 
color of the muscles is altered, the periosteum and the osseous structure 
in the vicinity are injected and inflamed. A rapid effusion of pus into 
the synovial cavities of joints, not unfrequently occurs in phlebitis, puer- 
peral fever, erysipelas, and in cases of contamination of the blood by 
some morbid matter. In one instance of this kind occurring after a 
thecal abscess in a finger, we found the synovial membrane forming the 



INFLAMMATION OF THE SYNOVIAL MEMBEANE. 



661 



margin of one of the ligamenta alaria of the knee-joint manifestly in- 
jected, and fringed with a number of various-sized villous projections. 
These consisted of a fibro-homogeneous, granulous substance, imbedding 
numerous glomeruli. A layer of similar matter was spread over the 
whole of the synovial surface, which was not injected with blood. The 
cartilage was ulcerated in some part of its extent, its surface rendered 



Fig. 342. 





From a ease of secondary depot in knee-joint, the same as described in the text, in the next page. 

(c) A cartilage-cell, immensely hypertrophied, lying in fibrous stuff. 

(b) A villous process springing from the synovial membrane. 

(a)' A strip of fibrous tissue containing three enlarged cartilage-cells — one is also figured separately. 

irregular by superficial erosions, and its texture altered to a lax fibroid 
stuff. The cartilage-cells in these parts were most remarkably changed, 
containing sometimes 20-25 celloid masses in their interior, instead of 
the two or three which they might contain in their normal state. The 
inter-cell substance was entirely deprived of its natural consistence ; it 
broke down under slight pressure. The following description of the 
condition of a joint which had been long in a state of suppuration is so. 



662 INFLAMMATION OF THE SYNOVIAL MEMBRANE. 

faithful and life-like that we cannot forbear transcribing it. Rokitansky 
says: "The quantity of purulent fluid effused into the cavity of the joint 
is generally considerable, and the capsule is, consequently, much en- 
larged ; the synovial membrane is lined with a firm, shreddy layer of 
lymph, which is dissolving into pus, and a soft, purulent precipitate, 
which can be easily removed, adheres to the cartilages." The term 
precipitate, which is here employed, is worth noticing, as Rokitansky 
states most strongly, in a previous paragraph, " that no exudation is 
deposited on that portion of the synovial membrane which covers the 
cartilage;" if any is found there, it is to be regarded as a " secondary 
precipitate' from the general exudation. This circumstance strongly 
confirms our view of the disposition of the synovial membrane. The 
layer of fibrin, lining the synovial membrane, " is opaque and lustre- 
less, its surface is rough, and serum is infiltrated, and blood in small 
spots extravasated through its tissue, as well as through that of the 
fibrous capsule of the joint, and neighboring cellular structures. As 
the disease advances, the infiltration and thickening of the neighboring 
structures increase, they become filled with a gelatinous, lardaceous, 
white product, in the midst of which fibrous tissues, capsules, ligaments, 
or aponeuroses, can no longer be recognized. Here and there, in the 
mass, there are cavities of different dimensions, the lining of which is 
vascular, spongy, and granulating, and the contents purulent. The 
muscles near the joint are pale and flabby, infiltered and attenuated. 
At length the infiltration reaches the subcutaneous cellular and adipose 
tissues, and the integuments become fixed to the disorganized structures 
beneath. The diseased joint then presents the following external ap- 
pearance : it is swollen, and always more or less bent ; it feels every- 
where soft and flabby, or in some spots flabby, in others firm, elastic, 
doughy, and at the same time tuberculated ; the integuments over it 
are tense and pallid, leuco-phlegmatic, or they are traversed by varicose 
veins. 

At length ulceration commences, and advances in various directions. 
"Externally, the capsule ulcerates in one or more spots, and then the 
soft parts adjoining it. In some instances large openings form in the 
capsule, and connect the joint with ulcerated cavities in the soft parts ; 
in others, mere sinuses are formed; but in either case they open exter- 
nally through the skin, and occasion and maintain a discharge of the 
contents of the joint. Internally, the inter-articular cartilages and the 
ligaments ulcerate, the cartilage covering the bones, when brought into 
contact with the matter, is destroyed in the way that has been men- 
tioned, and the ulcerative inflammation attacks even the bones, if they 
have not been involved already. The cavity of the joint appears like a 
cloaca, surrounded with a gelatino-lardaceous mass; the integuments 
covering it are of a dark red hue, and are especially discolored at the 
orifices of the sinuses. The joint contains pus or sanies of an offensive 
odor and variously discolored; the repeated hemorrhages which take 
place when there is acute caries of the bones, very frequently giving it 
a red or brown tinge ; the ligaments ulcerate, and the cartilages sepa- 
rate partly, or entirely, from the bones; the osseous surfaces are laid 
bare, their compact wall is destroyed, and the spongy tissue is exposed, 



INFLAMMATION OF THE SYNOVIAL MEMBRANE. 663 

infiltrated with pus, and ulcerating, and surrounded on all sides by osteo- 
phytes of various shapes; remains of the fibrous structures of the joint, 
pieces of loosened cartilage, and of necrosed bone, are mixed with the 
matter discharged from the joint. The soft parts, and the entire bones 
belonging to the diseased joint, are wasted, most of the fat is absorbed, 
the muscles are remarkably blanched and thin, and the bones, being 
generally in a state of eccentric atrophy, are soft and fragile. More 
or less quickly after the disease has reached this stage, spontaneous dis- 
locations, as they are called, ensue." The exudative product of inflam- 
mation, in some instances, is, according to Rokitansky, converted into 
tubercle. This occurs when there is a great amount of general tuber- 
cular disease. The articular extremities of bones are sometimes affected 
by tuberculosis simultaneously with the synovial membrane, sometimes 
before it. 

Inflammation may attack the cellular tissue around joints, causing 
effusion of coagulating fluid and consequent swelling, with subsequent 
formation of pus. One or more spots only may be affected, so that 
small, local deposits of pus are produced; or the whole may be involved, 
and the joint become enveloped in a large abscess. In its later stages, 
the disease extends to the synovial membrane and the cartilages, or re- 
covery may take place, the joint remaining sound. 

Pulpy degeneration of the synovial membrane is a very curious and 
peculiar disease, with the exact nature of which we are yet scarcely 
acquainted. It was first described by Sir B. Brodie, as a morbid alter- 
ation of structure peculiar to the articular lining membranes, nothing 
analogous having been observed in the serous sacs. He says: "The 
disease seems to commence in the reflected portions of the synovial 
membrane, converting them into a light brown, pulpy substance, vary- 
ing from a quarter to a half, or even a whole inch in thickness, inter- 
sected with white membranous lines and red spots, formed by small 
vessels injected with their own blood. It then attacks the synovial 
membrane of 'the cartilages,' beginning at their edge and extending 
gradually over them, ulceration in those cartilages going on correspond- 
ency, till the carious or ulcerating surfaces of the bone are exposed. 
The cavity of the joint sometimes contains pale-yellow fluid in the floating 
flakes of lymph, or pus, which is discharged externally by ulceration ; 
but sometimes neither. Or abscesses may exist in the altered synovial 
membrane itself, without communication in the joint." We have given, 
in the Pathological Report for 1848-49, a detailed account of the dis- 
position and structure of the synovial membrane thus peculiarly altered, 
from which we extract the following summary: The new growth formed 
prominent fringes of a soft, grayish structure, which overlapped and 
encroached considerably on the surface of the articular cartilage. The 
marginal zone of the cartilage, for a varying extent, was converted into 
a kind of fibrous tissue, and blended with the altered synovial mem- 
brane. More internally the cartilage was grooved on the surface, pro- 
bably so as to correspond with the overlying fringe. The fibrous tissue 
into which the cartilage was transformed was of an imperfect kind, not 
divided into distinct fibres, and not containing any of the natural cells, 
but strewed over with numerous oil drops and yellowish molecules. The 



664 



INFLAMMATION OF THE SYNOVIAL MEMBRANE. 



change in the cartilage was effected by extraordinary enlargement of its 
cells, which were crowded with an endogenous growth of young cells 
containing each a small oil drop and much clear fluid. At the margin 
of the cartilage, which was obliquely truncated, the change was most 




(a) Vertical section of cartilage in process of absorption towards the left, and overlapped by the vascular- 
ized pulpy synovial fringe. The edge of the cartilage where it is obliquely truncated is continuous with the 
fibrous tissue on the left hand. 

(b) Healthy cartilage-cells from the right-hand side, more magnified. 

(c) Greatly enlarged cartilage-cell, containing young cells. 

(d) Loculus, from thickened synovial membrane, filled and surrounded with nuclei. 

advanced; in the interior the structure was quite natural. The pulpy 
synovial tissue consisted principally of well-formed nuclei and granular 
matter, with which were mingled a few fusiform and circular cells. 
These elements were contained in an enveloping membrane, very thin, 
of whitish aspect, and nearly homogeneous texture. There existed 
scarce any trace of stromal fibres, but a good many large vesicles, or 
loculi, formed of almost homogeneous walls, and filled with material 
similar to that which surrounded them. Delicate-walled bloodvessels 
ramified through the mass, but not in great numbers. It seems very 
probable that the altered synovial tissue promotes and is concerned in 
the absorption of the cartilage. The disease almost always occurs be- 
fore the middle period of life. " In general, it can be traced to no evi- 
dent cause; but occasionally, it is the consequence of repeated attacks 




INFLAMMATION OF THE SYNOVIAL MEMBRANE. 665 

of inflammation." It rarely occurs elsewhere than in the knee, but has 
been seen in the ankle, and in a joint of the fingers. Sir B. Brodie 
classes it with malignant disease, but from this it is differenced by well- 
marked characters. 

Another very curious alteration, which is sometimes observed in the 
synovial membrane, consists in its free internal surface being covered 
by a growth of large villous processes, quite perceptible to the naked 
eye, which hang into the cavity of the joint, and present a shaggy ap- 
pearance. They are not developed on the surface 
of the cartilages. They have sometimes the form Fig. 344. 

of simple threads, or flattened shreds, or their free 
extremities are split into filaments, like a tassel, or 
they have a club shape, or resemble melon-seeds, 
hanging singly or in clusters from each stalk. In 
structure, they consist of a fibroid material, con- 
taining, we believe, in many instances, more or less 
fat, and approaching herein to that peculiar form 
of fatty tumor which is called Lipoma arbor esc ens. 
The healthy texture of the articulation is not ma- 
terially interfered with, at least in many cases. 
They seem to be the result of a slow exudation of „ Fimbriated knee-joint ; 

, ^ i • i • i t> " ie surface of the patella is 

plasmatic matter, which may pass into a low form the only part unoccupied, 
of organization. 

Inflammation of the ligaments, both acute and chronic, is said to 
occur; but Wickham states that, according to his experience, "the liga- 
ments are the last of all the different parts diseased, and that it is very 
common to find the ligaments perfect, even when every other texture is 
either altered or destroyed." From Mr. Key's account, it seems that 
inflamed ligaments become thickened and more pulpy than natural. 
The areolar tissue which penetrates among their fibres becomes highly 
vascular, and is probably concerned in producing the softening and ul- 
ceration of their substance, which sometimes takes place. 

Relaxation of the ligaments may be the result of long-continued 
chronic inflammation, or of simple disuse of the limb. In the latter 
case, it has been known to proceed to such an extent as to allow the 
head of the femur to slip out of the acetabulum. Frequent and heavy 
strains may produce a similar effect ; Mr. Wickham mentions a case in 
which the leg was so much bent outward at the knee as to be at nearly 
right angles with the thigh. 

Loose cartilages (so called) are not unfrequent in the cavities of joints. 
They are usually from the size of a millet-seed to that of a pea, but have 
been met with as large as a walnut. In shape, they are more or less 
oval and flattened. Their surface is smooth, as if invested by a serous 
covering, which they sometimes evidently possess, when they are attached 
to the synovial membrane by a pedicle of varying length. Formations 
of this kind commence in the subserous tissue, and as they enlarge 
gradually, make their way inward towards the cavity of the joint, in 
which at last they become free by the dissolution of the pedicle. Others 
are formed by a condensation of fibrinous coagula; "they are dis- 
tinguished," Rokitansky says, " by their uniform smoothness through- 



m 



MORBID CONDITIONS OF CARTILAGE. 



out, by a delicate albuminous investing membrane, and frequently by 
their manifest arrangement in concentric laminae." They never contain 
any of the characteristic cells of cartilage, and appear to consist solely 
of compressed fibrillating exudation. Occasionally, they are lodged in 

Fig. 345. 




Trochlea of humerus ; showing formation and connection of loose cartilaginous bodies. 

ulcerated cavities of the normal cartilage, which might give rise to the 
idea that they were truly fragments of this tissue, cut out, as it were, by 
the process of ulceration. We do not believe, however, that this ever 
happens. Calcareous matter is sometimes deposited in the substance of 
these false cartilages, and Mr. Rainey describes true bone lacunae, similar 
to those seen in the thin plates of the ethmoid, as existing in their 
interior. 1 

MORBID CONDITIONS OF CARTILAGE. 

It is somewhat doubtful whether a true hypertrophy of cartilage ever 
takes place ; but an apparent hypertrophy is not unfrequently observed. 
The thickness may be increased to treble of that which is normal; at 
the same time, the tissue becomes very soft and yielding, and shows a 
decided tendency to break up into fibres, which are arranged vertically 
to the surface. There is some evidence to show that, at a later period, 
cartilages, so altered, would waste and disappear. In advanced age, 
articular cartilages become considerably thinned — at least this is the 
case in the hip, and, probably, more or less in all joints that are exposed 
to pressure. Sometimes the cartilage is simply atrophied ; in other cases, 
it is replaced by a semi-translucent, and in others again, by a white 
fibroid tissue. Sometimes the cartilage seems itself to ossify, being 
converted into what is called the ivory or porcellaneous deposit. This 
is a peculiarly dense kind of bone; its Haversian canals being filled up 
by the earthy salts. Besides occurring as a gradual, almost unperceived 
change in the aged, it is also met with very constantly in the disease 
termed chronic rheumatic arthritis, of which we shall presently speak. 

1 A specimen removed from a knee-joint by Mr. Lane, exhibited, on section, a central 
cavity containing some fatty matter ; round this was a zone of hard calcareous deposit, 
so arranged at its inner part as to include cancelli. Lacunas existed in this zone. The 
outer zone consisted of a fibroid layer, imbedding very numerous oval and elongated nu- 
clear particles. This specimen was more than usually organized. 



MORBID CONDITIONS OF CARTILAGE. 667 

The free surface of cartilages is sometimes covered with a thin layer 
of lithate of soda; and the same matter may also exist in the substance 
of the cartilage, in the cancelli of the invested bone, and in the subsy- 
novial tissue. It is deposited as the result of gout. It is not uncommon, 
on opening joints which are not apparently diseased, to find the carti- 
lages more or less deficient at one or more points, and this especially 
in the parts where they have had to bear the greatest pressure. The 
cartilage is eroded more or less deeply, so that in the seat of the lesion 
the bone may be exposed, and this with scarce any traces of inflamma- 
tion in the synovial membrane. Sir B. Brodie " has many times observed 
a portion of cartilage of a joint wanting, and in its place, a thin layer 
of hard, semi-transparent substance, of a gray color, and presenting an 
irregular granulated substance." This indicates a partial atrophy, and 
destruction of the cartilage, with imperfect replacement of it by a fibrin- 
ous exudation. We have lately examined the knee-joint of a female, 
aet. 47, who died of pleuro-pneumonia, in which the cartilage of the 
femoral condyles, and of the patella, was manifestly in a state of chronic 
atrophy, or "usure," as it has been termed by Cruveilhier. There was 
a slight injection of one of the natural synovial fringes, but no trace of 
inflammatory action ; the joint, externally, appeared quite healthy, and 
no complaint had been made respecting it during life. The cartilage 
of the patella was most affected ; it presented, at its external part, an 
unequal, irregular surface, about the size of a fourpenny piece, which 
was softened in texture, and roughened by small grayish prominences. 
The surrounding cartilage was in a commencing state of similar change. 
In a vertical section of the part most affected, it was seen that the cells 
near the free margin were enlarged and multiplied, while the matrix at 
the margin broke up into fibres of various size, quite separate from each 
other, the larger still imbedding some of the cells. The accompanying 
cut illustrates this degeneration of cartilage. 

Ulceration of cartilage, occurring as an acute or subacute affection, 
has been much inquired into, and our knowledge respecting it has be- 
come tolerably definite and exact. It was formerly much disputed, 
whether the change was effected by the action of the vessels of the car- 
tilage itself, or those of the synovial membrane, on the incrusted bone. 
Now, however, we know certainly, that human articular cartilage is 
entirely devoid of vessels; and we have good reason to believe that 
those of the surrounding textures are not the effective agents in the 
ulcerative process. Mr. Key, who contends most for the influence of 
the vascular fringes, allows that ulceration may occur as a primary 
affection, independent of the other textures of the joint. If we refer, 
as we may fairly do, to the instance of the cornea, as a very analogous 
tissue, we can scarcely hesitate to admit that ulceration is essentially 
an alteration of the nutrition of the affected texture, and that the influ- 
ence of the adjoining vessels upon it is only secondary. The perforat- 
ing ulcer of the stomach is also a striking instance of the truth of this 
position. It being then admitted that ulceration of cartilage is pro- 
duced by a special disorder of its own nutrition, we proceed to inquire 
what has been ascertained respecting the nature and the stages of this 
diseased action. These were admirably set forth by Mr. Goodsir, in 



668 



MORBID CONDITIONS OF CARTILAGE. 



his well-known paper on the process of ulceration in articular cartilage, 
an extract from which we subjoin: " If a thin section, at right angles, be 



Fie. 346. 



Fig. 347. 




W 



: - : pi^££^.o®m% 



mmi$mmmi 



\. :■:■■■&■■&■■ !■■■; : ! ■;. ..'-^.o?.^ '■&'q., ; n, 



# 






if 



:;-■:.■'-••'■ .'■'•"•■• >■•?*:■'•"*.. .•::'.: r:':i H 



i 4> ^ 






%: 



IplI 

" : -it 



WW 







Tertical section of cartilage of patella, in 
state of usure. The free margin presents 
a number of fibres. The left-hand figure 
represents one of these fibres, more magni- 
fied, and containing some groups of cor- M 
puscles. 



Diseased articular cartilage magnified 240 diameters, 
showing the enlargement of the corpuscles, the more 
superficial of which are throwing out their contents into 
the softened inter-corpuscular substance— Redfern. 



made through the articular cartilage of a joint, at any part where it is 
covered by gelatinous membrane in scrofulous disease, or by false mem- 
Fig. 348. 




,-:\€S§ 



Microscopic view of a perpendicular section of articular cartilage, showing its surface occupied by fibrous 
bands formed by the splitting of the hyaline substance. These bands rendered it velvety in appearance to 
the naked eye.— Redfern. 



MORBID CONDITIONS OF CARTILAGE. 



brane, in simple inflammatory condition of the joint, and if this section 
be examined, it will be found to present the following appearances: on 
one edge of the section is the cartilage unaltered, with its corpuscles 
natural in position and size. On the opposite edge is the gelatinous or 
false membrane, both consisting essentially of nucleated particles, inter- 
Fig. 349. 




Fibrous tissue with included cells and nuclei; formed, as above described, on the surface of the cartilage of 

the patella. — Kedfern. 

mixed, especially in the latter, with fibres and bloodvessels ; and, in the 
former, with tubercular granular matter. In the immediate vicinity, 
and on both sides of the irregular edge of the section of cartilage, 
where it is connected to the membrane, certain remarkable appearances 
are seen. These consist, on the side of the cartilage, of a change in 
the shape and size of the cartilage-corpuscles. Instead of being of their 



Fig. 850. 









fii 



■ : - ' : : ..:.-. i ■■■■■. 

ii^^M IP 



Vertical section of cartilage in a diseased knee-joint, showing the cells enlarged, granular, and bursting. 
On the right, and above, their contents are seen mingling with a fibrous and granular mass which occupies 
the surface.— Redfern. 

usual form, they are larger, rounded, or oviform; and instead of two or 
three nucleated cells in their interior, contain a mass of them. At the 
very edge of the ulcerated cartilage, the cellular contents of the en- 
larged cartilage-corpuscles communicate with the diseased membrane by 
openings more or less extended. Some of the ovoidal masses in the 
enlarged corpuscles may be seen half released from their cavities by the 



670 



MORBID CONDITIONS OF CARTILAGE. 



removal of the cartilage; and others of thein may be observed in the 
substance of the false membrane, close to the cartilage, where they 
have been left by the entire removal of the cartilage which originally 
surrounded them. If a portion of the false membrane be gradually 
torn off the cartilage, the latter will appear rough and honeycombed. 
Into each depression on its surface, a nipple-like projection of the false 
membrane penetrates. The cavities of the enlarged corpuscles of the 
cartilage open on the ulcerated surface by orifices of a size proportional 
to the extent of absorption of the walls of the corpuscles, and of the 
free surface of the cartilage. The texture of the cartilage does not 
exhibit, during the progress of the ulceration, any trace of vascularity. 
The false membrane is vascular, and loops of capillary vessels dip into 



Fig. 351. 



Fig. 352. 










<^i ^Cr ' 



Deposition of opaque calcareous matter, commencing in the 
walls of the cartilage-corpuscles. — Eedfern. 



"■Tl 



Drawing of ulceration of cartilage. 

(a) Vertical section of ulcerating carti- 
lage, magnified. 

(b) Naked-eye view, showing two ulcer- 
ated depressions. 



the substance of the nipple-like projections, which fill the depressions 
on the ulcerated surface of the cartilage; but, with the exception of the 
enlargement of the corpuscles, and the peculiar development of their 
contents, no change has occurred in it. A layer of nucleated particles 
always exists between the loops of capillaries and the ulcerated surface. 
The cartilage, where it is not covered by the false membrane, is un- 
changed in structure. The membrane generally adheres with some 
firmness to the ulcerating surface; in other instances, it is loosely ap- 
plied to it; but in all, the latter is accurately moulded to the former. 
In scrofulous disease of the cancellated texture of the heads of bones, 
or in cases where the joint only is affected, but to the extent of total 
destruction of the cartilage, over part or the whole of its extent, the 
latter is, during the progress of the ulceration, attacked from its at- 
tached surface. Nipple-shaped processes of vascular cellular texture 
pass from the bone into the attached surface of the cartilage, the latter 
undergoing the change already described. The processes from the two 



MORBID CONDITIONS OF CARTILAGE. 671 

surfaces may thus meet half-way in the substance of the cartilage, or 
they may press from the attached, and project through a sound portion 
of the surface of the cartilage, like little vascular nipples or granula- 
tions. The cartilage may be thus riddled, or it may be broken up into 
scales of varying size and thickness, or it may be undermined for a 
greater or less extent, or be thrown into the fluid of the cavity of the 
joint in small detached portions, or it may entirely disappear." Mr. 
Goodsir believes the cells of new formation, the nucleated particles of 
the false membrane, to be the immediate agents in the absorption of the 
cartilage. We have had several opportunities of verifying the above 
account, and have already mentioned two instances in which we observed 
a similar change in ulcerating or wasting cartilage. We subjoin a short 
account of another observation, because it seems to show pretty clearly 
the non-essentiality of the vascular false membrane, or at least of its 
apposition to the affected part, to the process of ulceration. A child, 
set. 4, died with a vast abscess surrounding the right femur; the hip- 
joint was sound, but inflammation had extended to the knee, the syno- 
vial membrane of which was inflamed, and contained some pus. There 
was an irregular ulcerated surface, of about the size of a shilling, de- 
nuding the bone on the trochlear surface of the femur. One of the 
synovial folds was much injected ; its tissue was thickened by interstitial 
deposit, and adhering to its margin were some masses of exudation, con- 
sisting chiefly of amorpho-granular matter, imbedding numerous non- 
nucleated pus-like corpuscles. The injection of the synovial fold was 
very marked; its capillaries were distended, and it presented a strong 
contrast to other parts of the membrane, which were, however, thick- 
ened by and covered with exudation. The layer of exudation adhering 
to the edge of this fold was partially vascularized; but it did not appear 
that the vessels were continuations of those of the synovial membrane. 
There was no adhesion between the ulcerated portion of the cartilage 
and the vascularized false membrane, nor did the two seem to have been 
in apposition. Near the part where the bone was exposed, there was a 
small spot of ulceration of the cartilage in progress; it showed to the 
naked eye two well-marked shallow depressions, and an intervening 
elevation, with a thin investing gelatinous layer, v. b. Fig. 353. In 
the deeper and healthy parts of the cartilage, as seen in a vertical sec- 
tion, the cells were small and elongated, containing one or more oil- 
molecules, with faint granulous matter and a clear fluid. Nearer the 
surface they were a little larger, and had the same contents. The 
matrix in both these parts was natural, and moderately opaque. At 
some distance from the free surface, the matrix became suddenly much 
more transparent, of a pale, homogeneous aspect. The cells in this 
part were swollen, and of a round shape, appearing to be distendeM by 
a clear fluid, in which floated some oil- molecules. They were not much 
more numerous, except on the ulcerating border, which was pretty even, 
and covered with escaped cells. There was a good deal of oil, in the 
form of large and small drops, scattered about; but this did not seem 
to proceed from the cells or the matrix of the cartilage, in neither of 
which was there much oil visible ; the latter, in particular, appeared 
simply to liquefy. The investing gelatinous layer consisted of coarse 



672 SCROFULOUS DISEASE OF THE JOINTS. 

granular matter, imbedding escaped cartilage-cells and corpuscles like 
those of pus. The bone subjacent to the cartilage was of a reddish 
color, was somewhat softened, and its cancelli contained, besides fat- 
cells, multitudes of granular cells and nuclei. Dr. Redfern has arrived 
at the following conclusions from his able inquiries into the subject of 
ulceration of cartilage : " Ulceration in articular cartilage differs from 
that in other tissues, in neither being accompanied by exudation, nor 
attended with pain ; differences which depend on the absence of vessels 
and nerves. Ulcers in articular cartilages heal by transformation of 
the surrounding cartilage-tissue into fibre ; but those occurring in other 
textures are cured by the formation of a cicatrix out of newly-exuded 
blood-plasma." 



SCROFULOUS DISEASE OF THE JOINTS. 

No doubt can exist of the propriety of the distinctive name given to 
this affection, although its course does not seem to be exactly similar to 
that of scrofulous disease of other parts. The articular extremities of 
the bones are the primary seat of mischief; they become preternaturally 
vascular and much softened, so that they are easily cut with a knife, 
while " a transparent and afterwards a yellow cheesy substance is de- 
posited in their cancelli." From the observation above mentioned, we 
are inclined to think that granular cells, formed in the primary exuda- 
tion within the cancelli, play some part in the absorption and removal 
of the earthy salts of the bone. As the disease of the bone advances, 
ulceration of the cartilage commences on its attached surface in the 
manner described in the extract we have given from Mr. Goodsir's paper. 
Before, however, this can take place to any great extent the articular 
lamina, so well investigated by Mr. Birkett, must be removed. This 
consists of a thin lamina of dense bone containing large lacunae with 
scarce any canaliculi, which bounds and closes in the cancelli on the 
surface incrusted by the cartilage. Until this is removed, no vessels 
can shoot into the nipple-shaped processes of false membrane which dip 
into the cartilage. The osseous tissue gradually wastes and is absorbed, 
it undergoes a true caries ; sometimes also a part dies and may exfoliate. 
In the fifty-first case related by Sir B. Brodie there was a small portion 
of dead bone thrown off into the cavity of the left elbow, while in the 
right knee, though it presented no manifest indications of disease, and 
admitted of perfect motion, the bones were unnaturally vascular and 
softened ; and an irregular cavity, occupied by little more than medulla 
and a reddish fluid, had been formed in the mid-part of the lower extre- 
mity of the femur. In cases of this kind, it is not at all unfrequent to 
find several joints affected with the same morbid change in various stages. 
As the whole of the articulating surface is generally involved in the dis- 
ease, the attachment of the cartilage becomes loosened at all points, and 
it is therefore, even at an early period, much more easily detached from 
the bone than is natural. Sometimes, as Sir B. Brodie mentions, in the 
advanced steps of the disease, nearly the whole of the cartilage is found 
forming an exfoliation instead of being ulcerated. "As the caries of 



DISEASE OF THE SPINAL COLUMN. 



673 



the bones advances, inflammation takes place of the cellular membrane 
external to the joint. Serum and afterwards coagulated lymph is effused; 
and hence arises a pulpy and elastic swelling in the 
early, and an oedematous swelling in the advanced, 
stage of the disease. Abscess having formed in 
the joints, it makes its way by ulceration through 
the ligaments and the synovial membrane, and 
afterwards bursts externally, having caused the 
formation of numerous and circuitous sinuses in 
the neighboring soft parts." This disease of the 
joint especially affects children ; it is the essence 
of the morbus coxarius which is so very common 
among the offspring of the poorer classes. It 
rarely occurs after the age of thirty. Sir B. 
Brodie cautions us against supposing that all in- 
stances of increased vascularity and softening of 
bone are of the same nature as the disease just 
described. Simple caries, resulting from inflam- 
mation, may produce the same effect, and it is only 
the deposition of yellow cheesy matter within the 
cancelli which can be regarded as truly distinctive. 
The youth of the patient, the simultaneous affection 
of several joints, and the existence of scrofulous 
disease in other parts, are also circumstances which 

will aid us much in forming a correct judgment. M. Lebert, however, 
denies that the yellow cheesy matter is anything more than concrete pus ; 
he has rarely found any tuberculous matter in bone undergoing caries 
or necrosis, even in cases of disease of the vertebrae with tuberculosis 
of several organs. We doubt whether in this M. Lebert has not been 
led into error, by attaching too much importance to his so-called tubercle 
corpuscles. Scrofulous matter may contain corpuscles, much more de- 
veloped than those of tubercle, and yet there will be little difference 
in the nature and behavior of the two products. Rokitansky and Mr. 
Paget recognize both circumscribed and infiltrating deposits of tuber- 
culous matter in bone. 




Destruction of cartilage in the 
knee -j oint . — Lis ton. 



DISEASE OF THE SPINAL COLUMN 



The joints of the vertebrse are very liable to be affected in nearly the 
same way as other articulations of more perfect development, so that a 
brief account of their morbid states will properly follow here. The 
cancellous tissue may be the seat of the scrofulous disease just described, 
occasioning caries and deposition of cheesy matter in the cavities. "In 
these cases ulceration may begin on any part of the surface, or even in 
the centre of the bone; but in general the first effects of it are percepti- 
ble where the intervertebral cartilage is connected with it, and in the 
intervertebral cartilage itself. In other cases the vertebrse retain their 
natural texture and hardness, and the first indication of the disease is 
ulceration of one or more of the intervertebral cartilages, and of the 
43 



674 



DISEASE OF THE SPINAL COLUMN. 



surfaces of bone with which they are connected." These cases may be 
considered analogous to those of primary ulceration of the cartilages of 
diarthrodial joints. "There is still another order of cases, but these 
are of more rare occurrence, in which the bodies of the vertebrae are 
affected with chronic inflammation, of which ulceration of the interver- 
tebral cartilages is the consequence." To this we have not any ana- 
logue among the more ordinary diseases of joints. "In whichever of 
these ways the disease begins, if not checked in its progress, it proceeds 
to the destruction of the bodies of the vertebrae and intervertebral car- 
tilages, leaving the posterior parts of the vertebrae unaffected by it ; the 
necessary consequence of which is an incurvation of the spine forward, 
and a projection of the spinous processes posteriorly." The chronic 
inflammation of the bones sometimes extends to the membranes of the 



Fig. 354. 



Fig. 355. 




Remarkable example of angular curvature 
and anchylosis. Prom a preparation in my 
museum . — Pirrie. 



Angular curvature from caries. From a preparation in 
my museum. — Pirrie. 



spinal cord, and when the curvature is very great the cord may be so 
compressed that it cannot properly discharge its functions. " Suppura- 
tion sometimes takes place at a very early period ; at other times not 
until the disease has made considerable progress. The soft parts in the 
neighborhood of the abscess become thickened and consolidated, forming 
a thick capsule, in which the abscess is sometimes retained for several 
successive years ; but from which it ultimately makes its way to the 
surface, presenting itself in one or another situation, according to cir- 
cumstances. In the advanced stages of the disease, new bone is often 
deposited in irregular masses on the surface of the bodies of the neigh- 
boring vertebrge ; and where recovery takes place, the carious surface 
of the vertebrge above coming in contact with that of the vertebrae below, 
they become united with each other, at first by soft substance, after- 
wards by bony anchylosis. This disposition to anchylosis is not the 
same under all circumstances; it is much less where the bones are af- 
fected by scrofula than where they retain their natural texture and 
hardness; and this explains wherefore, in the former class of cases, a 



ANCHYLOSIS. 675 

cure is effected with more difficulty than in the latter. Occasionally, 
portions of the ulcerated or carious bone lose their vitality, and having 
become detached are found lying loose in the cavity of the abscess." 
When a large abscess has formed, the pressure of the matter on the sur- 
faces of the contiguous vertebrae may cause an extensive caries far beyond 
the limits of the original disease. 



ANCHYLOSIS. 

The term is derived from the Greek ayx^, which signifies a curve of 
a joint, and was applied to such cases of stiff joint as remained fixed in 
a curved, not a straight position, which was distinguished by the term 
opdoxu-kov. The process which produces anchylosis is very similar to 
that which unites the two ends of a fractured bone, and the union in 
both cases may be effected either by soft fibroid tissue or by actual 
bone. For the production of anchylosis it is essential that the cartilage 
encrusting the articular bony surfaces should be wholly, or in great 
part, removed. When this is effected, and the conditions of the inflamed 
parts are such as do not tend to the production of pus, but of plastic 
exudation, the capillaries, which have entered the processes of false 
membrane from the bony surfaces, meet and anastomose together ; so 
that the vascular systems of the two bones are in free communication, 
while the intervening fibrinous exudation gradually undergoes change 
into a dense fibroid tissue, mingled, as Rokitansky says, with an abund- 
ance of fat. If the process stop at this point, soft or fibrous anchy- 
losis is the result. More commonly, however, under favorable conditions 
of perfect rest, proper food, and attention to the health, the exudation 
undergoes change into osseous substance, so that the two bones become, 
as it were, accurately welded together. Mr. South quotes the following 
interesting instance from Mayo, illustrating what we have described as 
the early stage of the anchylosing process : " A young man had a 
lacerated wound of the ankle, erysipelas came on, and matter formed 
around, and made its way into the joint, the cartilage of which became 
rapidly absorbed. The limb was removed two months after the accident. 
Upon a vertical section being made of the ankle, one common change 
was found to have taken place in both the joints, which the upper and 
under surfaces of the astragalus contributed to form. In each of these 
joints the cartilage had entirely disappeared ; and the denuded ends of 
the bones were joined together by a layer of semi-transparent and 
organized lymph, from a sixth to a quarter of an inch in thickness. 
This union by lymph was a step towards union by bone. One circum- 
stance appeared to me of peculiar interest. The interior of the bones 
was perfectly healthy ; but the surfaces to which the lymph adhered 
were, for the depth of one or two lines, extremely vascular." There is 
a kind of anchylosis which is denominated the spurious or false, most 
common after synovitis, and which depends on the presence of masses 
of exudation within the synovial capsule, with thickening of this mem- 
brane and of the ligaments. The condition of the muscles also seems 
to promote the fixed state of the articulation, the extensors being para- 



676 CHRONIC RHEUMATIC ARTHRITIS. 

lyzed and wasted, and the flexors, which exert in most instances a supe- 
rior power, being contracted, shortened, and atrophied. Anchylosis of 
the bodies of the vertebrae has already been alluded to as the mode in 
which a cure takes place after caries of their structure and ulceration 
of the intervertebral ligaments. It is clear from this that when the 
destruction of these parts has been at all extensive, the avoidance of the 
deformity of angular curvature is impossible. Anchylosis of some of 
the less important joints occurs almost naturally in old age. Some 
rare instances are recorded in which all the joints of the body became 
spontaneously anchylosed. 



CHRONIC RHEUMATIC ARTHRITIS. 

The chronic inflammatory nature of this affection is extremely well 
marked, but the essential dependence of it upon rheumatism is not so 
well demonstrated. It occurs not only after an attack of acute rheu- 
matism, but after injuries and bruises, and sometimes without apparent 
cause. It is very frequent in the hip, the shoulder, the knee, and the 
articulations of the hand. When it is fully established in the hip-joint, 
it is said, by Mr. R. Adams, rarely or never to extend itself to the 
other articulations. Sometimes both hips only are attacked. When 
the knee is the seat of the disease, or the shoulder, other joints will, 
generally, be found more or less implicated. In the case of the knee, 
Mr. R. Adams recognizes a first stage, " marked by evidences of sub- 
acute inflammation, such as pain, heat, considerable swelling. This is 
followed by a second period, in which the heat and swelling diminish, 
but the pain continues." The disease in the hip and shoulder is described 
by the same author as of a more chronic character from the commence- 
ment, not being attended with any sensation of increased heat, or ap- 
pearance of distension. A very marked diagnostic sign of this affection 
is, that pressing the articular surfaces together, and moving them, so 
as to produce crepitus, does not cause any uneasiness. A similar 
attempt in ulceration of the cartilages, or in articular caries, would 
cause severe pain. We quote, from Mr. W. Adams's communication to 
the Pathological Society, the following account of the appearances ordi- 
narily observed in the advanced stages of chronic rheumatic arthritis: — 
" In the hip-joint. — 1st. Great enlargement and irregularity of shape 
of the head of the femur, which assumes a mushroom-like form, in con- 
sequence of real or apparent flattening of its upper part, and nodulated 
masses and flattened ring-like layers of new bone, surrounding the edge 
of its articular cartilage, and extending to a variable distance over its 
articular surface. To this mushroom-like form, the apparent shortening 
of the neck, in consequence of its upper part being concealed by the 
overhanging margin of new bone at the edge of the articular cartilage, 
also contributes. 2dly. Absence of articular cartilage to a greater or 
less extent, and the eburnation of the bony surface. 3dly. Nodulated 
masses of new bone, from the size of a hemp-seed to that of a walnut, 
attached by thin peduncles to the synovial membrane on the neck of 
the bone, or to that of the capsular ligament — more or less spherical 



CHRONIC RHEUMATIC ARTHRITIS. 677 

when small, but flattened and irregular when of large size. In the os 
innorninatum. — 1st. Increased capacity of acetabulum. 2dly. Ossi- 
fication of the fibro-cartilaginous rim, or cotyloid ligament. 3dly. Ab- 
sence of articular cartilage to a greater or less extent, and eburnation 
of the exposed bony surface. 4thly. Irregular osseous growths (stalac- 
titic osteophytes) on the surface of the bones external to, and imme- 
diately surrounding the joint. In the knee-joint, the appearances were 
essentially similar to those in the hip ; new osseous growths, of irregular 
form, surrounded the margins of the articular cartilages of the femur 
and tibia ; and pedunculated osseous growths, in considerable numbers, 
and of all sizes, were attached to the synovial membrane, both in the 
notch and lining the capsule. In addition, however, the articular car- 
tilages on the condyles of the femur presented a thickened, nodulated 
appearance, in their central parts." Mr. R. Adams, describing the 
condition of the shoulder-joint, says : " The capsular ligament is occa- 
sionally increased in thickness, and its fibres are hypertrophied ; and it 
is generally more capacious than natural, showing that effusion of syno- 
via to a considerable amount had existed, although the external signs 
of this phenomenon are not usually evident. When the interior of the 
synovial sac is examined, it will be found to present evidences of having 
been the seat of chronic inflammation. Bunches of long organized 
fringes hang into the interior of the synovial sac ; and many of these 
vascular fimbriae, which in the recent state are of an extremely red 
color, surround the corona of the head of the humerus. We also notice 
rounded cartilaginous productions, appended by means of membranous 
threads attached to the interior of the various structures which compose 
the joint." The size and shape of these bodies is various. The long 
tendon of the biceps muscle is very commonly adherent to the superior 
extremity of the bicipital groove, while that portion of it which nor- 
mally passes upwards, and takes its attachment to the upper margin of 
the glenoid cavity, is destroyed. The articular surface of the humerus 
is very much enlarged, and extends itself over the greater and lesser 
tuberosities, and even over the highest part of the bicipital groove. 
The head appears to be in a line with the shaft of the bone, instead of 
being directed upwards, inwards, and backwards. The cartilage is 
more or less completely removed, the bone in some parts eburnated, in 
others porous. Nodules of bone, vegetations, as Mr. R. Adams terms 
them, are thrown out around the margin of the head. The glenoid 
cavity of the scapula becomes much enlarged, and, losing its oval shape, 
assumes a more circular form. This, however, depends much on the 
position which the head of the humerus occupies. The depth of the 
articular cavity is increased by osseous productions thrown out around 
its margins ; its encrusting cartilage is removed, and the surface in 
part is covered by porcellaneous deposit, in part remains porous. The 
enlarged head of the humerus comes into immediate contact, in many 
cases, with the under surface of the coraco-acromial vault, causing ab- 
sorption and wasting of the tendons of the supra-spinatus and biceps, 
and the upper part of the capsular ligament. The acromion process, 
the outer extremity of the clavicle, and the coracoid process, in most 
cases become enlarged, though their under surfaces are worn and ebur- 



678 CHRONIC RHEUMATIC ARTHRITIS. 

Bated by the friction and pressure of the head of the humerus. Occa- 
sionally, however, they are found atrophied, or altogether removed. It 
is a remarkable circumstance, particularly noticed by Mr. R. Adams — 
from whose article, in the Cyclop, of Anai. and Phys., we have taken 
the foregoing account — that, in many cases, the acromion process is 
traversed in the line of junction of its epiphysis, "by a complete inter- 
ruption of its continuity, as if fractured." This has been considered 
by several observers, as well as the destruction of the long tendon of 
the biceps, to be the result of accidental violence. Cruveilhier is quoted 
by Mr. R. Adams as describing the bones of the carpus, in a case of 
chronic rheumatic arthritis of the wrist-joint, to be so confounded 
together into an irregular mass that it was difficult to say which part 
each took in the construction of the carpal region. The radius and the 
ulna undergo like changes to those which have been described above ; 
the lower surface of the latter, confronting the cuneiform bone, becomes 
smooth and polished, the inter-articular fibro-cartilage having been re- 
moved. The nature of the changes taking place in this disease have 
been admirably investigated by Mr. J. Adams, from whose communica- 
tion to the Pathological Society, 1850-51, p. 156, we extract the following 
account. Rokitansky regards the morbid process as an inflammatory 
rarefaction, attended with swelling and softening of the bone. " After 
furnishing an osseous exudation within the texture of the bone, and all 
around, an exudation which may be distinguished by its form and 
chemical composition, it terminates in consecutive induration." Mr. 
Adams, from his examinations, arrives at a different conclusion. He 
believes the process to consist : " 1st, in hypertrophy of the articular 
cartilage, generally occurring at the circumferential margin, but occa- 
sionally taking place towards the central parts of the articular surfaces. 
The new growth of cartilage takes place principally, if not entirely, 
near to the articular surface." It is very similar, though not quite 
identical with the original cartilage, a fibrillated character of the matrix, 
and the scattered, solitary, or imperfectly grouped arrangement of the 
nuclei being the principal points of difference." 2dly, "in the develop- 
ment of true osseous tissue in the hypertrophied cartilage, ossification 
commencing either in the newly-formed cartilage or at the junction of 
the new with the old cartilage. Ossification proceeds more rapidly in 
the newly-formed and forming cartilage, for its growth is probably 
simultaneous with the advancing ossification than in the old articular 
cartilage ; so that considerable masses of new bone are formed, altering 
the configuration of the articular extremities, whilst a layer of articular 
cartilage remains in its normal position. More slowly, but as perfectly, 
ossification takes place in this imbedded layer of articular cartilage. 
The process resembles the normal process of ossification in temporary 
cartilage in the intercellular matrix being the primary seat of earthy 
impregnation, and in the enlargement of the cells in the immediate 
vicinity of the bone." 

Effects of Dislocations. — The most common cause of dislocations is 
a violent strain or injury to the part ; but they may also come to pass 
spontaneously, either from abnormal relaxation of the ligaments, or 
from destruction of them in consequence of disease and muscular inac- 



MORBID CONDITIONS OF BUESJ1. 679 

tion. Dislocation, it is affirmed, may also occur congenitally. What 
we wish to notice here is, the changes which take place in the articu- 
lating surfaces when a dislocation has taken place and remained a long 
time unreduced. Rokitansky describes these as follows : " The capsule 
becomes enlarged, and the place of its insertion altered ; the articular 
cavities of the bones increase in size, and undergo various changes in 
form; and corresponding alterations are produced in the articular heads 
or prominences. In other cases, in which the dislocation is complete, 
the capsule wastes, and the bony cavities diminish in size, or are filled 
with masses of new osseous substance ; the displaced head of the bone 
loses its character, and a new joint is formed. The cellular structures 
which surround the dislocated head inflame, and frame a new capsule 
around it, which, for the most part, fits closely, is of fibroid structure, 
and has a serous lining ; whilst the pressure of the head, in its new po- 
sition, occasions a shallow, articular excavation beneath it. In other 
cases, instead of an excavation beneath the head, a mass of callus springs 
up around it, and forms either a hollow to receive it or a level surface, 
which the head may be flattened in order to fit ; or, lastly, the callus 
may project, and that which was the articular head be excavated to 
receive it. Sometimes the quantity of new bone deposited around a dis- 
located head is very abundant, and retains it firmly in its place. In 
dislocations of long standing, the pressure upon the vessels and nerves 
interferes with the nutrition of the luxated bone, and, like the soft parts, 
it is found in a state of atrophy." 

Morbid Conditions of Bursse. — These small synovial sacs are liable 
to be affected much in the same way as larger. They may be attacked 
by inflammation, more or less acute, or quite chronic, resulting from 
rheumatism, the abuse of mercury, or some other constitutional affection, 
or excited by violence or long-continued pressure. The effusion which 
takes place may, in cases of a chronic kind, be a simple synovial or 
serous fluid ; but, when the inflammation is more acute, it is either a 
turbid serum, with flakes of fibrinous matter floating in it, or actual pus. 
Suppuration sometimes is produced artificially, for the purpose of causing 
the obliteration of the cavity of the bursa. The matter sometimes makes 
its way directly to the surface of the skin, and is discharged ; but it 
often, also, escapes into the surrounding cellular tissue, and diffuses 
itself over a considerable extent. Sir B. Brodie describes this as being 
of common occurrence after inflammation of the bursa patellae, so that 
an abscess is formed between the skin and the fascia," covering the 
whole of the anterior part of the knee, and liable to be confounded with 
inflammation of the synovial membrane of the joint. When severe in- 
flammation supervenes, after the puncture of a large bursa, so much 
constitutional disturbance is sometimes occasioned that the patient dies. 
This is more likely to occur in persons who are in a state of bad health. 
The walls of an inflamed bursa sometimes become prodigiously thickened 
by the organization of layers of fibrinous effusion. There is a specimen 
in the Museum of St. George's, in which the walls of an enlarged bursa 
patellae are more than half an inch thick, while the cavity, which is com- 
paratively small, is traversed by reticulating laminae of false membrane. 
"When the inflammation has been of long standing," SirB. Brodie says, 



680 



MORBID CONDITIONS OF BURS^J, 



"it is not unusual to find, floating in the fluid of the bursa, a number of 
loose bodies, of a flattened oval form, of a light-brown color, with smooth 
surfaces, resembling small melon-seeds in appearance. There seems to 
be no doubt that these loose bodies have their 
origin in the coagulated lymph which was effused 
in the early stage of the disease; and I have had 
opportunities, by the examination of several 
cases, to trace the steps of their gradual forma- 
tion. At first, the coagulated lymph forms ir- 
regular masses, of no determined shape, which 
afterwards, by the motion and pressure of the 
contiguous parts, are broken down into smaller 
portions. These, by degrees, become of a regular 
form, and assume a firmer consistence, and at 
last they terminate in the flat oval bodies which 
have been just described." The synovial sheaths 
surrounding the flexor tendons of the fingers, as 
they pass under the annular ligament, are not 
unfrequently the seat of increased secretion of 
fluid, and of the formation of small bodies, com- 
pared by Mr. R. Adams to grains of boiled rice. 
"They are found in vast numbers in the same 
cyst, mixed with a more or less considerable 
quantity of glairy synovial liquid." They occa- 
sion, as they move to and fro, a distinct sensation 
of frotternent, and are quite identical with those described by Sir B. 
Brodie. 

What are called ganglions, are small collections of fluids in bursal 
cavities of new formation. They are most frequent on the back of the 
wrist and forearm. They do not seem to arise from inflammation, but 
rather to be of the nature of simple cysts. They are slightly movable, 
indolent, and painless, and appear to be situated "in the reticular tissue, 
which immediately covers the sheath of the extensor tendons." To the 
latter they are connected firmly, to the skin but loosely. The consistence 
of their contents varies from that of limpidity to that of thick jelly-like 
matter. 1 According to Velpeau, these cysts occasionally communicate 
with the articular synovial cavity. 




Enlarged bursa orer the patella, 
the result of pressure. House- 
maid's knee. 



1 Some fluid of this kind, which we examined, was coagulated, in great measure at 
least by nitric acid ; it contained a few nucleated granulous corpuscles. 



THE PATHOLOGICAL ANATOMY OF THE 
OSSEOUS SYSTEM. 



CHAPTER XLII. 

PRELIMINARY REMARKS. 

The peculiar rigidity of the bones, and the large amount of earthy 
matter entering into their composition, as well as a certain difficulty of 
making such close and frequent examinations of them as of other tissues, 
rendered their pathology a terra incognita, until John Hunter demon- 
strated the close analogy which exists between morbid changes in the 
hard and soft textures of the body. While we detect with comparative 
ease variations in the consistency, vascularity, and structure of the 
latter, the determination of these points in bone is scarcely ever at- 
tempted, unless we have to deal with very manifest lesions, owing to the 
greater physical difficulty which presents itself; hence our knowledge 
of the early stages of disease, and of the accompanying changes, is less 
satisfactory than it might be. Fine sections for microscopic examina- 
tion necessarily alter the relation of, or destroy, the soft parts that enter 
into the constitution of bone, and therefore deprive us of one important 
element in the diagnosis of morbid change. Still, much remains to be 
done in regard to investigating and describing alterations perceptible to 
the naked eye, and establishing the links connecting certain bone dis- 
eases with certain lesions of the system at large, with which we are 
already well acquainted. The labor necessary to gain this point is pro- 
bably greater than will be performed in the dead-house of an ordinary 
hospital ; and we must not expect a full solution of such recondite ques- 
tions of morbid anatomy until we have established endowed professor- 
ships, which may enable the incumbents to devote their energies and 
time solely to scientific purposes. 

We have passed over the consideration of monstrosities in other parts 
of the frame, or of their diseases during the foetal period. In our re- 
marks on the deformities occurring in after-life, we shall have occasion 
to allude to some congenital malformations which are persistent ; it 
would, therefore, be inconsistent to review in detail the intra-uterine 
anomalies affecting the bone. After birth, the functions of the bones 
may be said to remain almost dormant for some months; but a process 
of hardening and consolidation is preparing them for the greater tax 



682 PERIOSTEUM. 

that is to be made upon them when the infant learns to shift for itself. 
It is at this period that our attention is occasionally called to the state 
of the bones, from their development not taking place in a ratio with 
the general evolution of the frame. Instances are recorded of a preco- 
cious ossification of parts that normally are only membranous or carti- 
laginous in infant life ; but they are unusual. Thus, the fontanelles may 
close prematurely, or the epiphyses and shafts of the long bones be 
united by bone. Derangements are much more frequent in the oppo- 
site direction ; an arrest of osseous growth being caused by a general 
defect of nutrition more immediately acting upon the process of ossifica- 
tion, or inducing morbid states which indirectly affect the bones. 



PERIOSTEUM. 

The intimate anatomical and physiological relation of the periosteum 
to the subjacent bone renders it advisable first to consider the affections 
to which it is liable. In many instances, the pathologist would proba- 
bly find it impossible to determine whether disease has commenced in 
one structure or the other ; the more so, as periosteal morbid action may 
be followed by similar products as we see arising from primary disease 
of the bone. Incipient inflammation of the membrane is characterized 
by a red blush, a humid succulent appearance, and more or less of a 
serous effusion, causing a slight separation from the bone. The perios- 
teum may, as Lobstein 1 observes, be seen to present this condition in the 
vicinity of chronic ulcers or of old cicatrices. As the inflammation 
advances, the connection between the membrane and the bone becomes 
more lax, and the effusion exhibits a purulent character ; or the separa- 
tion may have been so sudden and extensive, especially in adynamic 
individuals, that, as Dr. Copland shows, before suppuration has time to 
supervene, gangrene of the periosteum and necrosis of the bone result. 
An inflammatory process in the periosteum is also essential to the repro- 
duction of bone after fractures, or other lesions of continuity calling for 
repair. The membrane is peculiarly obnoxious to syphilis and rheuma- 
tism — diseases which are prone to fasten upon the fibrous investment of 
the bones, and induce various secondary disturbances of a more or less 
serious character. Both chiefly affect the more superficial parts ; the 
periosteum of the skull, the sternum, and the tibia, being the points 
most commonly attacked. Syphilitic inflammation, or at least that 
which occurs in the course of syphilis, whether as a result of- the virus 
or of the mercurial treatment, is apt to occur in numerous detached 
spots, at which tumefaction, induration, the formation of new osseous 
matter, and necrosis, present themselves. Mr. Stanley 2 remarks, that 
the hardness of a syphilitic node does not in itself indicate its composi- 
tion, as he has found supposed osseous nodes to prove mere indurated 
periosteum. He also states that the pericranium differs from the fibrous 
investment of other bones in never becoming ossified. Rheumatic perios- 

1 Anatomie Pathologique, vol. ii. p. 83, 

2 On Diseases of the Bones, p. 346. 



PERIOSTEUM. 683 

titis, like the former, presents chiefly the chronic type ; it is more liable 
to occur in the vicinity of the joints, placed here to induce a peculiar 
form of bony deposit, to which we shall again refer. Another form of 
periostitis is that frequently met with in cachectic and scrofulous sub- 
jects; it is of a sluggish character, causing greater thickening of the 
membrane and closer adhesion to the bone, followed by suppuration in 
the tissue, and underneath or upon it. The small amount of pain and 
constitutional irritation resulting from a lesion, which, under other cir- 
cumstances, or in other constitutions, would give rise to violent symp- 
toms, is remarkable; while, in a therapeutic point of view, the curability 
of even very extensive lesions of this type affords a better ground for a 
favorable prognosis than we should expect a priori. This applies also 
to the cases in which scrofulous periostitis is followed by exfoliations of 
the subjacent bone ; in these cases, there appears to be generally a coinci- 
dent formation of new bone, sufficient to prevent not only a loss of 
strength, but even a deformity. In a practical point of view, we should 
look upon these local manifestations of the scrofulous cachexia rather as 
a tendency to concentrate diseased action at a distance from vital organs ; 
they ought not, therefore, to be hastily interfered with, but should be 
regarded rather as a safety-valve to the system, which may be allowed, 
and even encouraged to act, until the system itself is sufficiently invigor- 
ated to elaborate all morbid action. The rapid evolution of scrofulous 
affections of internal organs, after the cure of the disease just spoken 
of, as well as the arrest of the former by a local and superficial eruption 
of the disease, is of too frequent occurrence to permit a doubt of the 
influence exerted upon the system by scrofulous periostitis. One of the 
forms of scrofulous periostitis not unfrequently met with, is that giving 
rise to the severer forms of panaritium or whitlow ; the periosteum of 
the phalanges being the seat of inflammatory action. The longer the 
duration of periosteal inflammation in any part of the body, the more 
likely it is that the subjacent bone will become more or less affected by 
the process — a circumstance easily explicable by the physiological rela- 
tion existing between the two. It is probable that a large number of 
the osteophytic, and other osseous growths which form upon the bones 
under various circumstances, are more immediately the result of perios- 
titis. The large share which this membrane takes in the regeneration 
of fractured bones, and in the repair of loss of substance from other 
causes, as shown by surgical observation and physiological experiments, 
tends to confirm this view. An examination of the preparations of bones 
sawn through, contained in pathological museums, further establishes 
the point. Thus we see in St. George's Museum (prep. A. c. 10, H.), 
a femur considerably enlarged from inflammation; it is in fact a case of 
eccentric hypertrophy ; but the section exhibits the shaft of the bone, 
though more compact and denser than normally of the ordinary dimen- 
sions, traceable through the deposit which has been derived from the 
periosteum. This deposit, in its turn, exhibits a cancellous texture ad- 
joining the original surface of the femur, bounded by a compact lamella 
in contact with the periosteum. Here we could scarcely assume the new 
osseous matter to have been directly formed by the old bone, because 
in that case we should expect to see either a more entire fusion between 



684 BONK. 

the old and the new formations, or the latter presenting a more complete 
identity with the former. 

Females are liable to a peculiar form of periostitis, especially after 
parturition; Mr. Stanley, who has drawn attention to this point, states 
that it is remarkable on account of the severity of its effects, and on 
account of its liability to cause an error of diagnosis; it effects the 
pelvis, and mostly its posterior part; and when it occurs near the hip- 
joint, its symptoms so much resemble those of disease of the joint, that 
the two are apt to be confounded. A correct diagnosis is material, as 
the affection is very amenable to treatment. 

Mr. Stanley describes a malignant disease of the periosteum, which 
he has met with on the bones of the hip, and which he attributes to long- 
continued and repeated attacks of inflammation, altering its structure, 
and giving rise to the growth of a fungous excrescence upon the mem- 
brane. This is sometimes soft and flocculent on its surface, with a firm, 
grayish, gelatinous base ; at others it consists throughout of a firm gela- 
tinous substance; it is both sensitive and vascular, and appears to possess 
a considerable tendency to involve the adjacent bone and soft parts ; 
after removal by operation, the disease is apt to recur in the adjoining 
tissues; it does not, however, appear, from the cases recorded by Mr. 
Stanley, that secondary formations of a similar character occur in other 
parts of the body; and he himself mentions one case in which, twenty 
years after the removal of a leg affected with this disease, the individual 
continued in perfect health. 

BONE. 

Authors commonly commence the consideration of the pathology of 
bone by an investigation of hypertrophy and atrophy — two conditions 
which are associated with, or are consecutive upon, various primary 
lesions; they are rather an element, or a symptom of diseased action, 
than the disease itself. The terms may be objected to, when we find 
them indiscriminately applied to morbid conditions essentially distinct; 
thus, hypertrophy is used to designate the increase of osseous matter, 
resulting from the physiological demands made upon the shaft of a long 
bone, after it has become curved by rickets, as well as to the numerous 
forms of bony growths, of a compact or cancellated structure, which we 
meet with upon the surface of the skeleton. Again, authors use atrophy 
as a generic term, under which they class diseases so remote in their 
character from one another, as absorption from pressure of a tumor, 
and mollities ossium. Under such circumstances, language is rendered 
rather a source of confusion than a means of intelligence ; and it be- 
comes a question whether it would not be advisable to eliminate from 
special pathology terms which indicate a single element in morbid 
changes, or rather the result of morbid processes, than the nature of 
the process. With this disclaimer, we shall first describe inflammatory 
conditions of bone, and incidentally devote a few remarks to hypertrophy 
and atrophy, but confine their application solely to an increase or a 
diminution in the normal size and constituents of the bones. 

Occasions are sometimes presented of viewing the various stages of 



BONE. 



685 



inflammation in bone ; and it is manifest that the osseous textures are 
subject to an increase in their vascular contents as are other organic 
tissues. The greater vascularity affects chiefly the lining membrane of 
the medullary and cancellous portions ; the ordinary symptoms of in- 
flammatory action may be noted in their incipient stages in surgical 
practice, but are scarcely seen in the dead-house, except in conjunction 
with more advanced disease in adjoining portions of the same bone. 
The first appreciable inflammatory changes in bone, to use Mr. Goodsir's 
words, "occur within the Haversian canals; these passages dilate, or 
become opened up, as may be seen on the surface of an inflamed bone, 
or better, in a section. The result of this enlargement of the canal is 
the conversion of the contiguous canals into one cavity, and the conse- 
quent removal or absorption of all the osseous texture of the part." 
Some softening is observed to follow inflammation in its early stages, 
and this will be accompanied by tumefaction, at first of a more succu- 
lent, subsequently of a more indurated character. Acute inflammation 
rarely takes place, except associated with mechanical injury; the dense 
structure, and the necessarily slower process of effecting a change here 
than in the soft tissues, are the reason why disease of the bone com- 
monly presents itself in the chronic form. The results of progressive 
inflammation are congestion, exudation, suppuration, caries, necrosis, 
with the coincident, and in many instances, as it were, accidental, in- 
crease of bone in adjoining parts. An enlargement of the affected por- 
tion is almost invariably met with, and may arise either from the changes 
which take place in its interior, or by a deposit on its surface, or from 
both. The specific character of the disease in which the inflammation 
arises determines whether the compact or spongy parts, the shafts or 
the epiphyses, of bones are effected, while the part of the skeleton 
attacked is likewise in a measure dependent upon certain uniform ten- 
dencies exhibited by various diseases. The 
spongy and medullary portions have the 
greater proclivity to take on inflammatory 
action, and of the hard bones, those that lie 
nearest the surface are the most liable to be- 
come inflamed. Unless resolution of the first 
or congestive stage takes place, an exudation 
of a rose-colored lymph, of a gelatinous ap- 
pearance, is effected, which as we may ob- 
serve in the same preparation, passes through 
a variety of shades, light-red, yellow, green- 
ish, or white, filling up the cancelli, or ex- 
panding the Haversian canals. This exuda- 
tion, in its turn, is absorbed, or becomes 
organized and converted into new bone, or, 
yielding to the continued morbid action, a 
destructive process ensues. In the case of 
its absorption, or of an arrest of the process, 

the parts may return to their normal condition, or the bone retains a 
permanently disorganized condition, which may present either an in- 
creased condensation and induration, or an abnormal rarefaction of the 



Fig. 357. 




Microscopic drawing of inflamed and 
softened bone. 



686 BONE. 

bone. Of the former, we have a good instance in the minute structure 
of gouty bone, where, as we are informed by Mr. Ure, 1 the Haversian 
canals are enlarged, and choked up with cretaceous matter, which also 
lines the medullary canal; the osseous corpuscles are also found to be 
larger than usual, rather irregularly scattered, and less distinct, and 
their canaliculi loaded with chalk, which is shown by analysis to be true 
carbonate of lime, 2 and not like the tophi of adjoining articulations, 
phosphate of soda; Mr. Ure states that he has found similar appear- 
ances in a femur of a person laboring under rheumatic arthritis. The 
latter, the rarefied state of bone, is that to which the term of osteo- 
porosis was given by Lobstein. This is a condition 3 commonly met with 
in rickety individuals, though it is also found in advanced life, in sub- 
jects who do not appear to be otherwise liable to rachitis. The affected 
bone presents an increase of size, and a diminution of density, owing 
to the tissue being expanded; the surface of the bone is irregular, and 
very porous. The periosteum, however, is not altered, nor do the sur- 
rounding textures exhibit any pathological changes. The medulla may 
be healthy, or changed in color and consistency. The canals of Havers, 
and the cells, will be found enlarged according to the seat of the injury, 
the gradual expansion inducing a thinning of the surrounding osseous 
layers, and eventually a communication between adjoining cavities. 
The condition may affect the compact or cancellous tissues alone or 
together. When the cortical layers are the seat of the change, the ap- 
pearances may induce the resemblance of caries. Lobstein describes 
the surface in this case as being covered with a multitude of longitudinal 
fibres, resembling those of a foetal skull. He attributes them to the 
development and the action of the periosteal vessels, which hollow out 
for themselves channels in the osseous substance. When this variety of 
cortical rarefaction is raised above the surrounding tissue, it resembles 
one form of osteophyte, and many of the preparations of caries pre- 
served in museums are referable to the same head. The rarefaction of 
the osseous tissue which constitutes osteoporosis, though often inducing 
a considerable increase of bulk, is essentially distinct from the process 
giving rise to the formation of exostosis, in which the generation of new 
osseous matter is the characteristic feature; the former being essen- 
tially an atrophic, the latter an hypertrophic, condition. The term spina 
ventosa, though one which has nothing but the prestige of antiquity to 
recommend it, is applied, among others, to affections belonging to the 
class just considered. We will not seek to perpetuate it by defining its 
characters, as it is an arbitrary designation, without any acknowledged 
and established meaning. Osteoporosis gives rise to fragility of the 
bones affected with it, and undoubtedly takes its origin in many of the 
dyscrasise which impair nutrition; though we meet with it occasionally 
in old age, as a mere effect of mal-nutrition, without any well-marked 
symptoms of a constitutional crasis, or of inflammatory action. An 

1 Lancet, 1847. 

2 In preparing sections of bone it is not unusual to employ putty powder; if some of 
this insinuates itself in the Haversian canals, we should necessarily find some carbonate 
of lime, which might mislead the observer. 

3 See Lobstein, Anatomie Pathologique, vol. ii. p. 116. 



BONE. 



687 



analogy undoubtedly exists between the forms of disease just adverted 
to and mollities ossium, but the latter presents so peculiar a type, and 



Fig. 358. 



Fig. 359. 




Suppuration in bone. 



Abscess in bone. 



is so evidently removed from anything like a local affection, or from in- 
flammatory causes, that we reserve its consideration for the sequel, and 



Fig. 360. 



Fie. 361. 





Abscess in bone. 



in bone. 



688 



CARIES. 



Fig. 362. 



now turn to examine the phenomena of suppuration, and the formation 
of abscess in bone. This may be diffused, or circumscribed, as in soft 
parts. It is secreted by the medullary membrane, and in its turn ex- 
cites more or less reaction in the surrounding textures. The diffused 
form is the most dangerous, and may arise both from severe mechanical 
injury, and from constitutional causes. It is commonly associated with 
phlebitis. The pus occasionally penetrates the bone, and an escape 
having been thus effected, a cure may be brought 
about without loss of limb, though the partial death 
of the bone will necessarily result. In circumscribed 
abscess we find a cavity, generally in or near the epi- 
physes, lined with a vascular membrane. A process 
of condensation or ossification is seen to take place 
in the vicinity of the abscess, while there is thicken- 
ing of the adjoining periosteum, and the surround- 
ing cellular tissue. It is probable, as Mr. Stanley 
remarks, that circumscribed abscess is in some cases 
attributable to the softening of tubercular matter, 
analogous to a pulmonary vomica, and that the con- 
tents may be discharged, leaving a cavity resembling 
a tuberculous cavity of the lungs. The circumscribed 
abscess, to use the words of the same author, usually 
remains of small size, but in some cases it has en- 
larged much beyond the natural limits of the bone. 
Such an enlargement of the abscess is not the effect 
of simple expansion of the walls of the bone; for in 
some of these cases the osseous wall of the abscess 
has increased in thickness with the enlargement of the cavity. The 
process consists of the combined action of absorption on the inside of 
the abscess, and of osseous deposit on its outside, whereby its osseous 
walls may acquire any degree of thickness, according to the predomi- 
nance of absorption in the one direction, or of deposit in the other. 




Limited internal ab- 
scess in lower part of tibia. 
Section of bone. — Prepared 
in Royal College of Sur- 
geons' Museum. 



CARIES. 



Chronic suppuration accompanies ulceration of bone, or, as it is com- 
monly called, caries, a slow absorptive process, which may occur in all 
bones, and every part of their structure, but is most liable to attack the 
cancellous tissue. The bone presents a more or less eroded and cribri- 
form appearance, and while absorption removes the tissue at one point, 
the surrounding parts are more vascular and tumefied than in the normal 
state, and the adjoining bone is commonly the seat of new osseous deposit ; 
or the softening process extends to a distance, and the bone is converted 
into a soft, pliable mass. The more the earthy matter has been absorbed, 
the fewer the number of osseous corpuscles that remain ; until they dis- 
appear altogether, and in their place we see only a granular substratum, 
with faint traces of the lamellar structure. The secretion is of a sani- 
ous, acrid, and fetid character, owing to the decomposition which takes 
place, and which is of diagnostic value during life, in determining the 



CARIES. 



existence or non-existence of disease of the bone. The discharge also 
contains minute portions of bony matter, showing the disintegration 
that is proceeding ; and it is very frequently mixed up 
with a grumous, flaky matter, resembling tubercle, evi- Fi g- 363 - 

dencing the scrofulous character of the disease. The 
discharge is apt to discolor the exposed bone, and itself 
become of a dirty brown, after exposure to air, as well 
as to blacken the tissues and probes brought into con- 
tact with it. Caries may commence in the interior of 
a bone, as well as on the surface. In the former case, 
it commonly makes its way outwards. When the caries 
is superficial, the Haversian canals are enlarged, and, 
to use Rokitansky's description, the tissues within them 
form, in part, a disorganized, soft, and shreddy mass, 
infiltrated with ichor, or spongy granulations, which 
easily bleed, grow from them luxuriantly, and advance 
outwards, over the rough surface of the bone, whilst, 
internally, they partially or completely fill the enlarged 
Haversian canals. In both cases, the bone appears 
porous or cancellous, but its color differs in the two. 
In the former, it is discolored by the contents of the 
Haversian canals ; in the latter, it obtains various 
tints of red, from the color of the granulations. When 
caries affects cancellous tissue, the bone acquires a livid caries. 

red color, especially if the granulations be at all 
abundant ; it becomes soft, resembles a mass of flesh, traversed by a 
delicate and brittle bony skeleton, and is easily cut with a knife, or 
yields to light pressure with a finger; lastly, it becomes swollen. The 
analogy of caries to ulceration of soft parts, is manifested in the mode 
in which a cure is established, as well as in its destructive stages. A 
healthy stimulus being set up, the absorption is converted into a repro- 




Fig. 364. 



Fig. 365. 




Caries of the elbow ; mainly 
affecting the condyle of the 
humerus. The vegetative ef- 
fort around the carious sur- 
face well exemplified. 

44 



Necrosis and caries combined ; in phalanges of the toes. In the 
upper, the carious cavity is represented as still containing its se- 
questrum. In the lower, the cavity and sequestrum are separate. 



690 



NECROSIS. 
Fig. 36G. 




Example of caries in the metatarsal bone of the great toe. Two carious ulcers ; each surrounded by- 
interstitial absorption as well as by attempts at reparative effort. 

ductive process ; the granulations restore the lost parts, if the chasm 
does not offer too great a tax upon the system, or the cicatrix is formed 
with more or less loss of the original substance. 



NECROSIS. 

Though caries often accompanies necrosis, the latter is as distinct 
from the former, as mortification differs from the ulceration of soft parts. 
Necrosis consists in the death of a portion, or an entire bone, resulting 
from various internal or external causes, which destroy its vitality. 
The necrosed part presents a dead white or waxy hue, or a greater 

Fig. 367. 




Necrosis of the head of the femur, acetabulum, and shaft, subsequent to amputation, a. Necrosed aceta- 
bulum and head, completely anchylosed and broken off at e from the neck. /, Remains of the articular sur- 
faces, closely united, b. Neck, and upper part of the shaft, a, New bone; 6, new bone undergoing necrosis; 
c;, bone still containing bloodvessels, and in various stages of inflammation; d t a membranous septum, marking 
the boundary of the dead and living bone. 

intensity of discoloration passing through various shades of green, brown, 
and black ; changes attributed to the influence of the atmosphere, or of 
the decomposing pus, though not necessarily due to either. The limits 
of the necrosed portion are not always easily defined, and, at all times, 
its outline is extremely irregular. It attacks chiefly the compact tissue, 
and is, therefore, most frequently met with in the shafts of long bones, 



NECROSIS. 



691 



from which it rarely extends into the epiphyses, though instances of its 
doing so are on record, as in the case of the tibia ; in the instance from 
which Fig. 367 is taken, the process is seen to extend through the neck 
of the femur into the head of the bone, and even to affect the innomi- 
natum. The relative frequency of its occurrence in different bones, is 
stated to be in the following order : the tibia, the femur, the humerus, 
the cranial bones, the lower jaw, the last phalanx of the finger, the 
clavicle, ulna, radius, fibula, scapula, upper jaw, pelvic bones, sternum, 
and ribs. Though a reparative process is commonly set up in the vicinity 
of the dead bone, which consists partly, in an attempt at separation and 
elimination ; partly, in the reproduction of new osseous matter around 
the necrosed portion, the effort of nature rarely suffices for this purpose, 



Fig. 368. 



Fig. 369. 



Fig. 370. 





Fig. 368. Necrosis of the femur, after amputation. At a, the sequestrum in process of separation. At b, 
the parent bone enlarged, and undergoing inflammatory change, necessary for detachment and repair. — 
Liston. 

Fig. 369. The sequestrum detached ; at its lower part, a, including the whole thickness of the hone. Gra- 
dually shelving upwards, as such sequestra usually do. — Liston. 

Fig. 370. Sequestrum; seen laterally; the external portions smooth, the internal rough and irregular. — 
Liston. 



and it is necessary that surgical interference should aid in the removal ; 
otherwise, the powers of the individual will probably be exhausted by 
the continued drain upon the system. A remarkable instance of the 
capabilities of an unaided constitution occurred to us, while investigating 
the effects of the powers of phosphorus in producing necrosis of the 
maxilla. A man came under our notice, in whom the destructive process 
had caused death of the body and rami of the lower jaw to such an ex- 
tent, that the entire bone, with the exception of the condyloid processes, 
came to lie loose in the cavity of the mouth ; a new jaw having, in the 



692 



NECKOSIS. 



interval, formed underneath, and not, as is usually the case, as a capsule 
to the necrosed part. The patient's mouth not being of sufficient size 
for the extraction of the bone, he sawed it across with his own hand, 
and then extracted it with ease. It is, however, rare for the sequestrum 
to be so completely separated from the living tissue by the inflammation 
and suppuration set up in its vicinity, and we even have much difficulty 
in determining sometimes, in the dead body, the limits of necrosis, as 



Fig. 371. 



Fig. 3: 



Fig. 373. 



I! 

tin 






! '- 



l\ 



Fig. 371. Acute necrosis of the tibia. The hone extensively perished at a ; the cortical formation has begun 
to form. Fibula, as usual, unaffected. — Liston. 

Fig. 372. Necrosis of tibia, more advanced. Cortical formation investing the greater part of the old bone. — 
Liston. 

Fig. 373. Necrosis of tibia, in the chronic stage. Cortical, or substitute bone complete, and consolidated. 
At several points cloacae seen, leading down to the sequestra. — Liston. 

its boundaries are imperceptibly lost in the healthy parts. Rokitansky 
describes the process of separation in the following words : " All round 
the necrosed portion, that is to say, at its margins and at the part 
where its surface is exposed to that of the healthy bone, the latter un- 
dergoes a gradual expansion, or rarefaction of its tissue, by the en- 
largement of its Haversian canals, assumes a rosy color, and becomes 
succulent. It gradually acquires an areolar structure, and is thus more 
rarefied ; at length it disappears altogether, and a red, soft, spongy 
substance, a layer of granulations, occupies its place. This change is 
produced by an inflammatory process, which gives rise to suppuration 
and granulation ; the bony tissue, beginning with the Haversian canals, 
is dissolved by the matter secreted within them, while the granulations 
which shoot forth at the same time, fill up the enlarged canals. The 
immediate result of this process, is the formation of a furrow of demar- 



NECROSIS. 



693 



Fig. 374. 




Necrosis of tibia. At a, 
the dead bone exposed. At 
b b, the papillae repre- 
sented, communicating 
through cloacae with the 
sequestrum. 



cation, which encircles the margin of the dead bone, and is filled up with 
granulations, and, so far as the process is completed 
on that surface, also of the living bone, which faces 
the dead, so far is the sequestrum separated." This 
process further establishes the analogy existing be- 
tween necrosis of bone, and the mortification of soft 
parts, while the description just quoted corroborates 
John Hunter's opinion, and the investigations of Mr. 
Goodsir. At the same time, the irregularity of the 
necrosed portion, and the luxuriant growth of granu- 
lations from the healthy part, often cause so close a 
dovetailing of the two, that it resembles actual or- 
ganic union, which has misled some observers in their 
conclusions respecting the nature of the process. 
Mr. Gulliver has shown, by his experiments, that 
dead bone may be mechanically introduced into the 
shafts of a healthy animal, and that a firm adhesion 
may be established between the two ; hence, it is a 
just inference that, after the morbid process is ar- 
rested, and a physiological healing act set up, the 
sequestrum may be retained as an innocuous foreign 
body. The experiments of Mr. Gulliver were also 
undertaken with a view to determining a question 
long agitated, whether or not bone, once dead, is 
liable to be reduced by absorption ; and his results 
give a decided negative to this doctrine, which had 
probably arisen from the circumstance that an exfoliated portion of bone 
is always smaller than the cavity from which it is removed, owing to 
the softening and suppuration in the healthy bone, which has allowed 
of the removal of the former. 

The process of reparation varies according to the seat of the necrosis 
and the parts implicated. 

Necrosis in the outer lamellae of a bone, when accompanied by de- 
struction of its coverings, including the periosteum, is described by Mr. 
Stanley as giving rise to the following changes: thickening and consoli- 
dation of the inner lamellae of the bone; inflammation of the surrounding 
periosteum, occasioning osseous deposit beneath the membrane and in 
its tissue, and in this way the dead bone becomes circumscribed by a 
thick projecting border of new osseous substance. By this means, the 
loss of substance is made to appear even larger than it really is. When 
the necrosis commences within the bone, a large deposit of osseous matter 
generally takes place under the periosteum, and in this manner the 
sequestrum comes to be inclosed in a capsule, which is perforated with 
openings termed cloacae; these are not filled up until* the dead bone has 
been removed. After this has taken place, granulations spring from 
the inner surface of the shell, and the cavity is gradually filled with 
bony matter ; so that, instead of a hollow shaft, we find a solid cylinder. 
A remarkable fact in connection with cloacae has been pointed out by 
Mr. Goodsir, viz : that they are almost invariably opposite a smooth or 
unaltered portion of the surface of the dead shaft, and that they result 



694 



NECROSIS. 



>3 



is 



I 



from the pus thrown off from the granulating internal surface of the 
new shaft making its way to the exterior, by those parts not yet 
closed, in consequence of having been opposite to por- 
Fi£. 375. tions of the old shaft, which had not afforded separate 

osseous centres. For those not familiar with Mr. Good- 
sir's researches, we may add that this fact is one upon 
which he bases his doctrine, that the reproduction of 
new bone depends not so much upon the periosteum as 
upon the spiculse of bone which remain attached to it, 
and which act as centres of ossification. "When the 
entire shaft of a bone," he says, "is attacked with 
violent inflammation, there is generally time, before 
death of the bone takes place, for the separation of 
more or less numerous portions of its surface. When 
the entire periosteum has separated from the shaft, it 
carries with it the minute portions of the surface of 
the bone. Each of these is covered on its external sur- 
face by the periosteum ; on its internal, by a layer of 
granulations, the result of the organized matter which 
originally filled the Haversian canals ; the gradual en- 
largement and subsequent blending of which ultimately 
allowed their contained vascular contents to combine 
with the layer of granulations just described, and to 
form the separating medium between the dead shaft 
and its minute living remnants. These minute sepa- 
rated portions, after having advanced somewhat in de- 
velopment, appear, when carelessly examined, particu- 
larly in dried specimens, to be situated in the substance 
of the periosteum, and have been adduced by the advo- 
cates of the agency of that membrane in forming new bones as evidences 
of the truth of their opinions." 

Mr. Stanley's views differ from those of the just-named author, inas- 
much as he attributes the main ossifying power to the periosteum itself, 
though he does not deny that a capability for restoring lost bone resides 
also in the portions of original bone, detached from its surface and re- 
maining attached to the periosteum, in the articular ends of the original 
bone and the soft tissues around the periosteum, or around the bone, if 
the periosteum has been destroyed. 

The surface of the new bone is at first very irregular and rugged ; 
and, if a section be made, the central cylinder and the external capsule 
exhibit a well-marked boundary. The more time has elapsed for the 
curative process to have been established, the more the normal appear- 
ance of the surface is restored, and the more completely the separation 
is obliterated. The period in which the necrosis and the subsequent 
reproduction take place varies much, both according to the cause of the 
lesion and the constitution of the individual. The more rapid and com- 
plete the death of a portion of bone, the more speedily, on the whole, 
the reparative process is found to take place; while a sluggish and pro- 
tracted dying of the osseous tissue, especially when resulting from causes 
connected with a cachectic state of the blood, or other constitutional 
maladies, will be followed by a slow process of regeneration. 



Cloacae. 



RACHITIS, 



6yo 



RACHITIS. 

The most important and prevalent disease of mal-nutrition — to employ 
the most general term that suggests itself — which we have to consider in 
the osseous system, and which modifies the characters of other maladies 
that supervene, as it tends to affect the entire bodily frame, is that known 
as rachitis, or rickets. While frequently associated with inflammatory 
conditions, it is not essentially an inflammation ; and, while one of its 
symptoms is a diminution of the consistency of the osseous texture, it 
neither exclusively consists in rarefaction of the bone, nor does it mani- 
fest those organic and chemical changes which constitute the peculiar 
disease known as mollities ossium. Owing to one feature having been 
regarded by different observers as characteristic of the disease, analogies 
have been repeatedly set down as proofs of identity. While a general 
debility is the chief constitutional feature of the disease, a deficiency 
in the earthy matter of the bones is the chief local phenomenon ; yet, as 



Fig. 376. 



Fig. 377. 





Section of a rachitic tibia, from the King's 
College Museum. 



Section of the femur of a rickety child cut with a knife. 
The shaft consists throughout of cartilaginous and gelatinous 
substances, intermixed and disposed in cells ; it is observable 
that a greater quantity of cartilage exists in the middle of the 
shaft, and towards the interior curve, than at any other part. 
— St. Bartholomew's Museum, i. 34. 



Mr. Stanley correctly suggests, the rickety bone is not simply a soft 
bone, but it undergoes, during the development and subsidence of the dis- 
ease, a series of curious and somewhat complex changes. The affection 
is especially one of early childhood; the first symptoms being commonly 
manifested at the period when we expect the child to leave its mother's 
arms, and to assert its independence. Guerin found that, of 346 cases, 
209 were affected between the first and third years ; only three were 



696 



KACHITIS. 



congenital ; and 34 occurred between the ages of four and twelve ; 148 
were males, and 198 females. We commonly first perceive a change in 
the conformation of the lower extremities, which is commonly referred 



Fig. 378. 



Fig. 379. 



Fig. 380. 





Rickets affecting the femur. 



Rickets affecting the tibia. 



to premature attempts at walking, and the mechanical effect of the 
pressure of the trunk upon the undeveloped limbs. That physical in- 
fluences, in some measure, determine the curvature, may not be denied; 
but that they are but a trifling cause may be inferred from the often 
surprising rapidity with which, during a continuance of the physical 
influences, but under improved regimen and medical treatment, the 
curvatures are rectified. A contortion of the bones of the pelvis, of the 
spine, the thorax, the upper extremities, and malformations of the skull, 
may follow upon those of the legs. That the disease does not consist in 
a simple absence of the due proportion of phosphate of lime, is shown 
by the coincident tumefaction of the epiphysis, the swelled joints, which 
but too often add to the deformity just spoken of. The swelling depends 
upon the exudation of a reddish serum into the enlarged cancelli and 
canals, the osseous corpuscles, at the same time, exhibiting a deficiency 
or an entire absence of earthy contents; so that, in cutting a bone thus 
affected, the knife meets with no resistance. The periosteum, at the 
same time, is pulpy and thickened, and more than usually adherent to 
the bone. The chemical constitution of the bone appears to undergo a 
change beyond the mere absence of the lime-salts ; the character of the 
cartilaginous framework being itself altered in constitution. 1 There is 



1 In deference to the high authority of Mr. Stanley, and on account of the weight which 
his statements necessarily carry with them, we deem it our duty to advert to an error 



RACHITIS 



697 



a diminution of the salts, varying according to the intensity of the dis- 
ease ; they may be reduced as low as eighteen per cent., while there is 



Fig. 381. 



Fig. 382. 




Rickets affecting the humerus. 



a uniform increase of fatty matter to about six per cent.; it also appears 
that the fluoride of calcium, of which there is always an appreciable 
amount in healthy bone, is absent in rickets. 

In the analysis of rickety bones, it is important to select the bone 
before the reparative process is set up. When this is effected, the 
swellings subside, and the distortions may, by the mere improvement of 
the general health, be much diminished, and even altogether removed ; 
or, if this be impossible, a deposit of bone takes place in such a manner 
as to correct the infirmity, and give the patient a limb useful for the 
ordinary purposes of life. The supplementary ossification is found, on 
a vertical section of a long bone, to be chiefly on the concave side; so 
that this part of the shaft may present double and treble the thickness 
of the opposite side. The structure, at the same time, is very dense, 
and of ivory texture. In flat bones, as in those of the skull, which is 
generally unduly large in rickety subjects, there is a uniform thicken- 
ing, which becomes a matter of serious importance in regard to the in- 
tellectual development of the individual, when the cranial cavity is con- 
tracted. That this is the case in many cases of idiocy, and especially 
in that form to which cretinism leads, is very probable. In some in- 
stances, the thickening of the bone affects the capacity of the foramina; 
thus, it has been observed that the foramen ovale has been narrowed 

which has crept into his chapter on Rickets (Stanley on the Bones, p. 218). He states 
that in rickets it has been shown that the cartilage yields neither chondrin nor gelatin ; 
this is based upon an analysis given in Simon's Animal Chemistry (Syd. Soc. Ed. vol. ii. 
p. 407), of a case of osteo-malacia, and not of rachitis. 



KACHITIS, 



by an enlargement of the base of the occipital foramen in epilepsy. 
In this disease, osteophytic projections are frequently met with, "which, 
however, do not come under the head of rickety productions. A pecu- 
liar form of disease of the cranium has been described by Elsasser, 1 as 



Fig. 383. 



Fig. 384. 




Permanent curvature of the spine, with rotation, produced by rickets. 

occurring in rachitis, and characterized by softening, thinning, and per- 
foration of the occiput. The bone is atrophied, soft, and porous; and 
numerous openings are observed along the lambdoidal suture, and in 
the body of the bone, with the exception of the occipital protuberance. 
The perforations may amount to as many as thirty ; and in place of 
bone, they are filled up only by the dura mater and pericranium, which 
are adherent to one another. It is not necessarily a fatal disease ; 
about one-half of the cases are said to prove fatal under symptoms of 
cerebral and spinal irritation. The affection commonly manifests itself 
between the third and sixth month of infant life ; the child exhibiting 
much restlessness, and a fear of all contact with the occiput. If it sur- 
vives, the usual rickety distortions of the skeleton supervene. 

To conclude the subject of rickets, and to avoid repetition, we will at 
once examine the malformations to which it gives rise in the various 
parts of the skeleton. 

We have already had occasion to allude to curvature of the lower 

1 Der weiche Hinterkopf, ein Beitrag zur Physiologie und Pathologie der ersten Kind- 
heit. Stuttgart, 1843. 



RACHITIS. 



699 



extremities ; it is one of the most ordinary symptoms of rachitis ; it 
varies in amount from a slight deviation of the bones of the leg from 
their ordinary shape and direction, to the most extravagant distortion, 
instances of which are preserved in most anatomical museums. The 
effect of such irregularity is to diminish the stature of the individual, 
and to render his gait clumsy ; but even if the distortion has been rec- 
tified or anticipated, the effect of the constitutional derangement is to 
stunt the growth. Mr. Stanley expresses himself thus on the subject : 
" In long bones, the defective growth in length is often such that they 
are not more than half their natural dimension ; but in the direction of 
their thickness it is not so constant ; thus, thigh-bones, a third or even 
a fourth shorter than natural, are often of their natural thickness. 
Occasionally, other phenomena are observed in the rickety skeleton ; 
some of its bones are distorted, whilst others are of their natural figure 

Fig. 385. 




x3>T&x±S 



Example of limbs deformed by rickets. — Liston. 



and length ; but from the failure of growth in the direction of their 
thickness, are so slender as to present the characters of extreme atro- 
phy. In the lower limbs the weakness of the system, which gives rise 
to curvatures in the bones, also occasions a yielding of the ligaments of 
the knee and ankle-joints ; hence these distortions of these joints, from 
the yielding of their ligaments, become part of the phenomena of 
rickets. And there are instances of such distortions of the knee and 
ankle-joints, unaccompanied by any bending of the bones. 1 



Stanley on the Bones, p. 224. 



700 KACHITIS. 

The distortions of the pelvis resulting from rachitis constitute a sub- 
ject deserving the serious attention of the accoucheur; their bearing 
upon the health and life of the married female ought to stimulate the 
medical man to have an especial regard to the prevention of pelvic mal- 
formation in the female child. A sort of natural protection appears to 
be aiforded to the pelvis against the inroads of rachitis, for numerous 
instances are recorded in which individuals, with well-developed rickets 
in the lower extremities and spine, escaped any distortion of the pelvic 
bones. With few exceptions, the irregularities of the pelvic diameters 
are due to rickets ; they are caused by lateral contraction, by an ap- 
proximation of the acetabula, by antero-posterior narrowing, from an 
advance of the sacrum, or by an asymmetrical deformity, due to an 
arrest in the growth of one-half of the pelvis. In all these cases the 
mechanism of parturition will be interfered with in proportion to the 
amount of malformation, and it is the brim which will be found to be 
chiefly at fault, though each part individually, or all collectively, may 
be involved in the deformity. " In most cases of partial deformity at 
the brim," observes Dr. Ramsbotham, 1 "the lateral diameter is in- 
creased in size nearly in the same proportion as the conjugate is dimin- 
ished; but however much the width from ilium to ilium may exceed the 
ordinary dimensions, the increased space thus obtained will in no degree 
make amends for the diminution from the sacrum to the pubes ; because 
it is necessary that there should not exist less than a certain quantity 
of available room in every direction to permit the child's transit." 
From the sacrum having to support the entire spinal column, the lower 
lumbar vertebrae and the base of the sacrum are very apt to be thrown 
forward where there is deficient cohesion, and the consequence will be a 
diminution of the conjugate diameter. In this case the diameter of the 
outlet is frequently found enlarged. The ilia will not present the usual 
expansion, the crests of the ilia will be nearer to one another than in a 
normal pelvis, and the female will probably also present a hollow-backed 
appearance. The sacrum is commonly deprived of its concave form, and 
exhibits a more rectilinear anterior surface, or as Smellie has observed, 
the vertebrae that compose it ride over one another, and form a pro- 
tuberance in the part that ought to be concave. These malformations 
cause those varieties in the form of the pelvis, which have been termed 
the elliptical, heart, or kidney-shaped, or figure of eight pelves. An 
oblique form, in which the ilio-pectinal eminence of one side approaches 
nearer to the promontory on one side than on the other, was first shown 
by Nagele to result from anchylosis of one sacro-iliac symphysis ; these 
pelves present a very characteristic appearance, and look as if one half 
of the pelvis and the acetabulum had been forcibly pushed over to the 
opposite ilium ; hence, the diameter from the sound sacro-iliac union to 
the opposite acetabulum will be very much diminished, while the interval 
between the anchylosed symphysis and the other acetabulum will be not 
only not diminished, but even increased. An excellent delineation of 
this and several other forms of distorted pelvis are to be found in Dr. 

1 The Principles and Practice of Obstetric Medicine, p. 39. 



SPINAL CURVATURES. 



701 



Ramsbotham's Atlas of Midwifery} The rickety distortions of the 
pelvis are probably never met with unaccompanied by spinal curvature; 
though the latter may occur without materially influencing the pelvic 
diameters. 



SPINAL CURVATURES. 



To one variety of spinal curvatures we have already alluded, that in 
which there is a projection inwards of the lumbar vertebrae — lordosis. 
This, however, is not ordinarily a primary affection of the spine, but 
one secondary to a curvature that has formed higher in the column, and, 
owing to the sigmoid form of the normal spine, calls for a compensating 
inclination in the opposite direction, which will necessarily take place 



Fig. 386. 



Fig. 387. 




Front view of lateral curvature of spine. 



Back view of same preparation. 



where there is a natural tendency forwards. It may also result se- 
condarily from obliquities of the pelvis and coxalgia, which woulcF, how- 
ever, act differently from the last-named lesion, inasmuch as they would 
induce a lateral deviation, as well as a projection forwards ; in so far, 
therefore, we differ from Mr. Shaw's views, who states that rickets have 
no share in producing lateral curvature in females. The main primary 
curvature of the spine belonging to rachitis, and the one that is more im- 

1 The Principles and Practice of Obstetric Medicine and Surgery, &c, by Francis H. 
Ramsbotham, M. D., London, 1841. 



702 SPINAL CURVATURES. 

portant than any other, on account of the frequency of its occurrence, 
as well as on account of the misery it inflicts upon the patient, and the 
great deformity produced, is kyphosis, also known as the angular cur- 
vature, Pott's malady, or the hump-back. This is almost invariably the 
result of inflammation and caries of the bodies of one or more of the 
dorsal vertebrae, or of their intervertebral substances, causing a collapse 
of several vertebrae, and consequent backward projection of their spines, 
and an approximation of the corresponding ribs. This disease univer- 
sally commences early in life; previous to, or about the period of, second 
dentition. A backward curvature occurs later in life as the result of 
senile atrophy of the bodies of the vertebrae, which has nothing in com- 
mon with the angular curvature of rachitis. Lateral curvature of the 
spine, or scholiosis, is rarely of a rickety character — it may be primary 
or secondary ; and presents an illustration of the law of compensation, 
equally with the curvatures previously considered. To avoid returning 
to the subject of spinal curvatures, we add the following remarks on this 
deformity. The primary curve generally occurs in the dorsal, while the 
compensating curvature, in the opposite direction, is found in the lumbar 
region ; and as the former is most frequently to the right, the latter, as 
a legitimate consequence, is most often to the left side. This distortion 
chiefly affects the female sex, and may be brought on by irregular mus- 
cular contraction, or by deficient action of the muscles of one side of the 
trunk, whether owing to want of exercise, or actual disease, such as 
pleurisy, or a paralytic affection. When the deformity results from 
rickets, the primary curvature will probably be found to have taken 
place in the lumbar region, while the dorsal is secondarily affected. 
The various malformations of the spine, which we have considered, are 
not always isolated ; but may be complicated with one another, as they 
are associated with deformities of other parts of the skeleton. That the 
thorax should be implicated whenever the dorsal vertebrae of the spinal 
column are affected, may be inferred from the relation the latter bears to 
the cavity, as well as to the ribs and the sternum combining to form it. 
The most common malformation of the thorax consists in a flattening 
of the sides, with a projection of the sternum, and a swelling of the 
sternal ends of the ribs ; this gives rise to the so-called pigeon-breast. 
It is very frequently, but not necessarily, associated with angular curv- 
ature of the spine ; for, in some cases of this disease, the ribs are 
raised and not flattened, and the lower end of the sternum, instead of 
being forced out, is actually drawn in, owing to the ribs not being 
lengthened, and the thorax, in consequence, assumes a more globular 
form. The thorax, in all cases of rickety distortion, approaches the 
pelvis unduly, and the abdominal cavity will thus be diminished. A 
depression of the sternum is very common in rickety subjects ; the 
whole length of the bone being marked by a more or less deep furrow, 
while the ribs are curved outwards. In both cases just mentioned, the 
sternum does not deviate from the mesial line ; a displacement of this 
bone, as well as of the thoracic parietes, accompanies lateral curvature 
of the spine ; in this case, to employ the description of Rokitansky, the 
thorax seems displaced in the opposite direction to the convexity of the 
dorsal curve, and the whole, or more commonly the lower end only of 



SPINAL CURVATUPwES. 703 

the sternum, swerves from the mesial line in the same direction ; the 
axis of the thorax itself inclines towards the convex side of the dorsal 
curve. One consequence of this deviation is, that that half of the thorax 
which is on the convex side of the curve is lower than the other, and 
approaches the pelvis ; when there is considerable curvature, the false 
ribs touch the ilium, or even project into the iliac fossa. But, in extreme 
cases of combined lateral and posterior curvature in the lower dorsal 
region, the thorax assumes the contrary position ; the ribs which pass 
from the concavity of the curve, force the chest to the opposite, the 
convex side ; the sternum diverges in the same direction, and the sunken 
half of the thorax is that on the concave side of the curve. The ribs 
are packed closer together on the concave than on the convex side ; hence 
the dimensions of the two lateral halves of the thorax are much altered ; 
the one on the concave side being contracted in its antero-posterior, but 
enlarged in its lateral diameter, while the reverse is the case on the 
convex side. The ribs, independently of any morbid change of structure, 
suffer considerable changes in form and outline in these deformities ; 
becoming more or less flattened, and being more or less turned on their 
axis, according to the dislocation of the vertebrae. The scapulas follow 
the distortion of the spine, and also exhibit other evidence of being the 
actual seat of textural derangement. The upper extremities present 
similar distortions to those seen in the lower extremities in very ad- 
vanced cases of rachitis ; the bones are ill developed, flattened, and 
variously curved, while the epiphyses are enlarged. Dr. Farre 1 states 
that he has met cases in which the upper extremities were bent by 
rickets, when the lower extremities and the rest of the body exhibited 
no signs of the disease. If any further proof were required that rickets 
is essentially a constitutional disease of the same family as scrofula and 
tubercle, and that its phenomena are not the mere result of mechanical 
pressure, such cases as those of Dr. Farre would afford it ; still, it is 
important not to overlook the physical influence of the weight of the 
body in promoting distortions, as we thereby obtain a valuable indica- 
tion for treatment ; for, while everything should be done to correct the 
vitiated state of blood, it is wise at the same time to remove all unneces- 
sary strain or pressure from any part of the frame, and to afford such 
support to the weaker points as mechanical ingenuity may suggest. 

1 Quoted by Mr. Stanley, loc. cit. p. 226. 



CHAPTER XLIII. 

ADVENTITIOUS GROWTHS. 

Under this head we shall consider the various enlargements of an 
homologous character, termed exostoses and osteophytes, and among 
which we may also class enchondroma, as well as the heterologous 
growths met with in bone. Bony tumors are commonly treated of as 
hypertrophies ; we adopt our arrangement partly for convenience, and 
partly because, as we have already stated, there is a broad distinction 
between the increase of the normal texture from mere hyper-nutrition, 
and the grotesque and extravagant forms springing out of various mor- 
bid conditions, to which we shall have to advert. Besides, the various 
forms of so-called hypertrophy are so frequently complicated with other 
diseased conditions, that it is impossible to determine which group pre- 
dominates ; nor can an arrangement of the tumors of the bone, as Mr. 
Stanley observes, be founded on the place of their origin, since many 
of them, identical in nature, arise indifferently from the periosteum, the 
compact, or the cancellous tissue of bone. 



ENCHONDROMA. 

We follow the example of Mr. Stanley, and consider, first, the abnor- 
mal production of cartilage in connection with bone ; or, as it has been 
termed, by Professor Muller, 1 enchondroma. It consists essentially of 
the same chemical and microscopic elements as true cartilage, and 
occurs more frequently in bone than in any other physiological tissue 
of the body: the bones of the fingers and toes being chiefly liable, though 
the ribs, vertebrae, and sternum are not exempt ; and cases are re- 
corded where the skull, the ilium, and the long bones have been attacked. 

Muller refutes the theory of its belonging to the family of scrofula, 
and attributes it to a peculiar formative process in bone, in consequence 
of which the embryonic primitive formation of cartilage takes place, and 
is kept up without the attainment of consolidation, or the more perfect 
organization of the products. The enchondroma appears to possess an 
independent vitality; it is radically cured by amputation, and appears 
never to enter into combination with any other changes in the bone. 

The tumor may originate within the cancellous tissue, or on the sur- 
face of the bone. The rapidity and extent of its growth varies, but 
generally it is of slow progress, and does not exceed the size of an 

1 Ueber den feineren Bau der Krankhaften Geschwiilste, 1838, p. 31. 



ENCHONDROMA. 705 

orange. When seated within the bone, the latter gradually expands 
with the development of the tumor, yet it is unaccompanied by pain or 
disorganization of the adjoining parts ; when external to the bone it 
exhibits a tabulated arrangement, and is surrounded by a fibrous sheath. 
The central variety presents a semi-elastic feel, and, on section, the 
knife passes through a thin crackling shell of bone, and then exhibits a 
white cartilaginous mass, which is occasionally found to contain some 
small cells, while, in some tumors there is an interlacement of fibrous 
tissue, in which the cartilage is imbedded, thus approximating to fibro- 
cartilage. They may be solitary, or occur in large numbers in the same 

Fig. 388. 




Euchondroma. Portion of the tumor removed from the lumbar vertebrae of a soldier, consisting of nodules 
of cartilage of various forms, with the microscopic features of fuetal cartilage. In the centre of some of the 
nodules there are small portions of cancellous bone ; the centres of others are softened. — St. Bartholomew's 
Museum, xiv. ii. 

individual. A remarkable instance is recorded in the Reports of the 
Pathological Society of London, 1 of a boy, in whom the slightest blow 
produced tumors of this kind. At the time of observation, he presented 
fifteen or sixteen of these swellings, on the fingers and metacarpal bones, 
one of which had attained the size of an orange, and required removal, 
solely on account of its bulk. The superficial variety, though microsco- 
pically and chemically identical with the central form, is characterized 
by the absence of an osseous shell; it is met with chiefly in the pelvis, 
on the cranium and the ribs. Lebert, who confirms the descriptions and 
all the details of Muller, gives some cases which fell under his own 
observation, one of which is particularly interesting, as showing the 
development of the cartilage, 2 the characters of which were not at once 
apparent to the naked eye from the highly vascular condition of the 
tumor. There is, generally, no disposition to ossification, though Koki- 
tansky states that he has observed this metamorphosis in the aggregate 
variety. The disease is chiefly met with in early life, and appears to 
be commonly due, as Muller has shown, to mechanical injury interfering 
with the due development of bone at that period. A case, accompanied 
by a delineation, in which there was partial ossification, is given in 
Vogel's Pathological Anatomy? 

' 1848-49, p. 113. 

2 Physiologie Pathologique, torn. ii. p. 212. 

3 Dr. Day's Translation, 1847, p. 582. 

45 



706 EXOSTOSIS. 



EXOSTOSIS. 

Osseous growths, consisting of true bone, are divided into exostoses 
and osteophytes ; the difference being marked rather by their form and 
their cause, than by the etymology of the terms, or their proximate 
constitution. As no theory is implied, and no false impressions are 
likely to arise by their employment, the names are more suitable than 
any other that we might select. Rokitansky defines exostosis as a purely 
bony mass, set upon a bone, forming with it an organic whole, and, 
where it is possible, originating or proceeding from the bone ; when its 
development is complete, and often at the beginning of its growth, its 
texture is homologous with that of its base and point of origin, whether 
compact or spongy. The former is the most frequent ; and it attains a 

Fig. 389. 




Several ivory exostoses clustered on the os frontis. 

hardness which has given rise to the term of Ivory exostosis; while its 
color is generally whiter than that of the bone from which it springs. 
Of the density of these exostoses the best proof is that operators are 
sometimes unable to remove them ; in St. George's Hospital Museum 
we find an exostosis from the orbit which sloughed off on the application 
of caustic, though Sir Astley Cooper had previously failed in sawing it 
off; there is another specimen in the same museum about one inch and 
a half in diameter, which took one hour to remove, and more than one 
saw was spoiled during the time. The exostosis may be entirely sessile, 
or it resembles a mushroom in its mode of growth, presenting a constric- 
tion at its base, which, though it may penetrate deeply, is so fine as to 
be imperceptible during life. Rokitansky so absolutely denies the com- 
plication of the compact and spongy exostosis, that we must specially 
refer to an instance which was exhibited at the Pathological Society of 
London, 1 in 1850, and which was remarkable both on account of its 
size, and because the base and pedicle were compact, while the remainder 
was cellular. The surface of these exostoses is smooth, and their out- 
line is commonly a segment of a circle, or of an ellipse ; their cause is 
an idiosyncrasy of the individual, not referable, as far as we can trace, 
to any definite constitutional taint. Some of the hard exostoses we 

1 See Report for 1850-51, p. 149. 



EXOSTOSIS. 



707 



meet with are manifestly mere hypertrophies of the normal prominences 
of the bone upon which they are seated ; thus, we see the tuberosity of 
the tibia, the styloid process and similar parts, give rise to these forma- 
tions ; an instance occurs in the malum coxae senile, where an exuberant 



Fig. 390. 



Fig. 391. 




Spongy exostosis on the femur, with a broad base and 
pointed processes directed downwards; the section 
shows a cancellous structure, surrounded by a shell of 
compact bone. The walls of the femur and the medul- 
lary cavity, in the situation of the exostosis, are per- 
fectly sound. — St. Bartholomew's Museum, i. 186. 




Exostosis of the femur. 



development of bone, probably owing to an arthritic process, takes place 
on the trochanter, and round the neck of the former, which it entirely 
overhangs. The bones of the skull are the most ordinary site of hard 
exostosis; it is also seen in the long bones, and in the pelvis, where they 
may prove an obstacle to parturition. The microscopic appearances are 
described by Rokitansky as exhibiting a very considerable number of 
peripheral lamellae, in which long corpuscles are observed. The Haver- 
sian canals are small, and far apart, many of them being surrounded by 
a distinct and isolated system of lamellae ; large tracts present no cor- 
puscles, while at other spots they are clustered together in dense groups. 
No new tissue is discoverable in the ivory exostosis. 

Spongy exostoses differ from the compact variety, in being composed 
of cancelli, containing medullary matter, and surrounded by a shell of 
bone; they vary much more in size and outline than the former; they 
spring from the cancellous or compact tissue of the bone, and their sur- 
face is continuous with that of the latter. In some cases the medullary 
cavity of the bone is immediately continuous with that of the exostosis, 



708 OSTEOPHYTES. 

so that this resembles a diverticulum. The spongy exostosis occurs at 
all periods of life — when it has attained a certain size it generally re- 
mains permanent. Rokitansky describes a process of condensation 
alternating with one of rarefaction; it is by the latter that he considers 
the growth of the spongy exostosis outwards to be chiefly affected. 



OSTEOPHYTES. 

The osteophyte was first characterized by Lobstein as a bony vegeta- 
tion which grows from the surface of the bone, or encircles the articu- 
lations, and offers the most varied forms. It is distinct from exostosis, 
in not forming well-defined local tumors that are more or less circum- 
scribed. It is not developed between the layers of the compact tissue, 
and their surface is rough, while the texture appears to differ more 
from that of the matrix than it does in the exostosis. The osteophyte 
sometimes bears a close resemblance to certain forms of coral. The 
osteophyte chiefly affects the more vascular portions of bones, as 

Fig. 392. 




Osteophytes, occupying the lower end of the femur. The whole exterior of the bones is roughened by the 
growth of irregular plates and pointed processes of osseous substance. A large canal, formed by ulceration, 
passes through the bone just above the condyles; around the lower part of each condyle is a broad rim of 
new bone. From a man aet. 35, with long-standing disease of the bone. — St. Bartholomew's Museum, i. 201. 

their articular ends, their rough lines, or, in the skull, the sutural car- 
tilages ; because, as Rokitansky remarks, it is generally the product of 
an inflammatory process in the superficial part of the bone, and in the 
periosteum; and hence it is very commonly found adjoining and sur- 
rounding not only portions which are inflamed, carious, or necrosed, but 
also spots of bone affected with various other diseases, which, in some 
stage of their existence, have occasioned a reaction in the tissue of the 
bone. Thus, we may refer the osteophyte, in an individual case, to 
simple inflammation, to rheumatic or gouty inflammation, to syphilis or 



OSTEOPHYTES. 709 

other causes. Gluge 1 appears to admit one variety of osteophyte only, 
which he describes under the term of osteophyton gelatinosum, as form- 
ing by the ossification of a fluid, gelatinous mass, effused on the surface 
of the bone ; the mass consists of granular cells, which are successively 
converted into cartilage and bone-corpuscles, which are disposed in rows, 
or layers, forming lamellae or spiculse at right angles to the bone; a 
reddish jelly-like fluid continues to surround the new bone, which is 
sometimes discharged in large quantities, and thus induces the erroneous 
assumption that we have to deal with carcinomatous degeneration. 

The diffused and fibro-reticular osteophyte of Lobstein, or what Ro- 
kitansky terms the velvety villous osteophyte, forms an osseous layer 
investing a bone that is otherwise healthy, sometimes removable, some- 
times firmly soldered to it ; it commonly presents the color of the bone, 
or it may be discolored ; by a lens it is found to present a furrowed 
surface, or to be composed of minute upright spiculse ; the small chan- 
nels which separate the osseous ridges being in the direction of the ves- 
sels of the periosteum. This variety is a very common accompaniment 
of inflammatory affections of the bone — it is the one which Rokitansky 
has observed to occur in females dying shortly after parturition, and 
has, therefore, called the puerperal osteophyte. The subject has not 
attracted the notice of English pathologists, but the authority of Roki- 
tansky's name renders some attention to it imperative. The layer of 
new bone, he says, varies in thickness from a very thin film to half a 
line, and more; generally occupies the frontal and parietal bones, but 
is sometimes found covering the whole inner surface of the cranial vault, 
and scattered in patches over the base of the skull. It exhibits the 
same mode of development as other forms of ossification ; it presents 
itself in all females who die either of puerperal disease, or from other 
causes, after the third month of pregnancy, or shortly after parturition. 
The complete incorporation of the exudation with the old bone causes 
an increased thickness of the latter, which is rendered more evident by 
repeated pregnancies. Rokitansky appears to regard the puerperal 
osteophyte as a uniform accompaniment of pregnancy; he does not 
seem to refer any of the sympathetic symptoms of this condition to the 
deposit, nor does he state that it is ever reabsorbed; but he enforces 
his position by the contrast which the frequency of this growth in wo- 
men who are pregnant, or have been recently confined, offers with its 
rarity in other persons. Exudations, he says, are deposited on the 
vitreous table in both sexes and at all ages, but they are less extensive 
than the puerperal osteophyte, and are usually confined to the neigh- 
borhood of the longitudinal furrow. Rokitansky's second variety of 
osteophyte is the splintered or laminated form, presenting itself in ex- 
crescences and lamellae several lines in length, of a conical shape, 
and terminating in a sharp point, which are found chiefly in the neigh- 
borhood of the cancellous parts of bone affected with caries. 

The next form of osteophyte which we have to consider is that which 
appears to be mainly the result of gouty and rheumatic affections; it is 
distinguished by forming excrescences of a warty and stalactitic cha- 

1 Atlas of Pathological Anatomy, Art. Osteophyte. American Edition. 



710 FIBROUS GROWTHS. 

racter, which are developed in the vicinity of joints of persons laboring 
under those diseases; the articular surfaces may be partially absorbed 
and present patches of enamel-like deposit, while the new osseous 
formations are thrown out, as it were, to support the defective mechan- 
ism. The osteophyte produced under such circumstances sometimes 
surrounds the joint and gives rise to a bony anchylosis. The bodies of 
the vertebrae are frequently found united to one another by osseous 
vegetations extending over two or more bones, like bridges ; they are 
analogous to the callus uniting fractures, but appear to be the result of 
some constitutional cause. Similar bony ridges are also observed to 
form between the ribs. 

The botryoidal, or cauliflower osteophyte, is described by Lobstein as 
a large sessile tumor, which is more or less compact at the base, and 
becomes spongy towards the surface, sometimes attaining the size of the 
head of a seven-months' child ; it occasionally merely forms a capsule 
to other heterogeneous matter, such as scirrhous, fibrous, fungous tumors, 
and the like. Lobstein's general theory of osteophytic growths is, that 
they consist mainly of an ossification of the tissues surrounding the 
bone ; according to this view, the diffused osteophyte is nothing but 
ossification of the cellular tissue, uniting the periosteum to the bone ; 
the fibro-reticular osteophyte an ossification of the periosteum itself; 
the flat and styloid form the ossified tendinous and aponeurotic fibres ; 
while the botryoidal variety, and that causing anchylosis, is attributed 
to ossification of the inter-muscular cellular tissue ; he denies the inflam- 
matory origin of the malady, and sets it down to a morbid hypertrophy; 
though, in that case, it would be scarcely consistent to speak of ossi- 
fication of the various tissues ; but we should regard it as essentially an 
outgrowth from the bone itself. This it certainly appears to be in the 
majority of instances; the original constitution or the morbid taint, 
rendering the bone a nidus for diseased growth ; the character of the 
latter is determined by its matrix. Lobstein's theory, however, may 
be held to apply in those rare cases in which we find the osseous growths 
produced indiscriminately in the soft parts and upon the skeleton ; Mr. 
Stanley 1 relates several instances of this kind, in which bony growths 
have appeared in various situations and in considerable number, either 
simultaneously or in quick succession. They generally occur early in 
life ; an arrest in the development of the morbid formation taking place 
at manhood, there is reason for assuming an hereditary predisposition. 



FIBROUS GROWTHS. 

Fibrous tissue is developed within or upon the bone, and gives rise to 
tumors, which, in the former case, are surrounded by an osseous en- 
velop ; they present more or less elasticity, according to the density 
of the inclosed growth ; offer a gray, opaque character, and yield gelatin 
on boiling ; they occur chiefly in spongy bones, as the articular ends of 
long bones in the vertebrae, the upper and lower jaw, the scapula and 

1 On the Diseases of Bones, p. 212. 



OSTEOID TUMOR. 711 

ossa innominata. Fibrous tumors may attain an enormous size : thus, a 
specimen in St. Bartholomew's Hospital, alluded to by Mr. Stanley, 
which grew from the humerus, measured three feet in circumference. 
Though non-malignant, there seems to be a tendency to reproduction 
after surgical removal, which has not been observed in enchondroma ; 
in which growth we noticed the occasional development of fibrous tissue, 
and the perfect security from relapse. Fibrous tumors and enchon- 
droma present no features by which they may be distinguished during 
life ; the lobulated surface is not peculiar to the latter. Mr. Adams 1 
exhibited a fibrous epuli springing from the cancelli of the lower jaw, 
of the size of an orange, forming a large lobulated mass. 



OSTEOID TUMOR. 

A transition form of osseous disease which intervenes between the 
simple bony tumors hitherto considered, and the malignant affections of 
bone, is the osteoid tumor of Professor Miiller ; or, as it is called by Mr. 
Stanley, the malignant osseous tumor. It has been alluded to by other 
authors under various terms ; but their introduction would only per- 
petuate the confusion which in pathology cannot be too much depre- 
cated. Miiller describes it thus : The osteoid tumor is irregularly lobu- 
lated, and is developed with more or less rapidity from the surface of a 
bone, and consists mainly of osseous tissue, in the interstices of which a 
non-ossified substance is found of the consistency of fibro-cartilage, which 
also forms the covering of these growths ; the bony matter is more or 
less porous, and presents all the characters of true bone, while the other 
constituent offers a grayish-white color, is somewhat vascular, and of 
firm consistency, and difficult to tear. The microscope displays in it a 
dense, fibrous network, with minute interstices, containing but few cells 
and nuclei ; it is not cartilaginous in structure or chemical composition, 
containing neither gelatin nor chondrin. These tumors result from a 
constitutional diathesis (an osteo-plastic diathesis, as it is termed by 
Lebert), leading to a local formation of bone, which, in its turn, is de- 
structive to the system. One tumor commonly appears on a bone, and 
numerous others subsequently form on different parts of the skeleton, 
and, at last, the osteoid growths are even developed in the soft tissues, 
whether the primary tumor have been surgically interfered with or not. 
Mr. Stanley, who gives three cases of the affection, states the charac- 
teristic features to consist in a tendency to grow round the lower part 
of the femur, just above its condyles, and around the upper part of the 
tibia, just below its head ; in a tendency to assume an oblong, rather 
than the globular form, which belongs to many other tumors of bone ; 
and in the absorbent glands, when contaminated in this disease, assuming 
the form of hard, isolated, movable tumors. 

1 Report of Pathol. Society, 1847, p. 114. 



712 CANCER. 



CANCER. 



Of the various forms of cancer, the encephaloid variety is found to 
affect bone most frequently ; it occurs either in the infiltrated form, or 
in the shape of a tumor. Either may be primary or consecutive, though 
idiopathic cancer of bone is of rare occurrence ; it is particularly liable 
to follow mammary carcinoma. Tuberiform cancer, according to Gru- 
veilhier, differs from infiltrated cancer as lobular from ordinary pneu- 
monia ; uncircumscribed cancer being more commonly limited to one 
bone, or part of a bone, while carcinomatous tumors are commonly the 
result of a cancerous cachexia. Cancer, in blocks, according to the same 
author, exclusively attacks the medullary tissue ; infiltrated cancer some- 
times affects exclusively the periosteum, the bone, or the medulla, or two 
or more at once ; the same individual may present each variety of site, 
showing the identity of the different forms. 

Cruveilhier considers the compact tissue of bones not in itself sus- 
ceptible of becoming t.he seat of tuberiform cancer ; in the few cases in 
which it has been found affected, he explains the process by a previous 
transformation of the compact into spongy bone, a notion regarded by 
Dr. Walshe as fanciful. In the infiltrated form of encephaloid, the 
cancelli and Haversian canals are filled with a reddish, fatty-looking 
substance, which causes an absorption of the cancellar septa, and thus 
becomes one of the various morbid conditions to which a great fragility 
of the bones is attributable. A case of primary medullary cancer of the 
femur, which has fallen under our notice, and was regarded, during life, 
as a rheumatic affection of the hip-joint, exhibited at the post mortem 
a remarkable fragility of the affected femur, the neck of which was 
broken during removal, the cancellar tissue of the bone appeared rarefied 
and filled with a reddish fat, and it was only by the microscope that the 
carcinomatous nature of the deposit, which was peculiarly well marked, 
was revealed. It is doubtful whether the infiltrated may be converted 
into the aggregated form; encephaloid tumors, however, in bone, attain 
a considerable size, distending into a cyst, or, according to Mr. Stanley, 
in some rare instances, being accompanied by increase of thickness of 
the bone, which gives to the tumor the character of a solid mass of bone. 
Cruveilhier remarks that it is characteristic of cancer not to give rise 
to any new development of bone. The shell occasionally yields and 
breaks, and, the growth of the cancer being unimpeded, increases with 
sudden rapidity, while the severe pain is lessened. The tissue presents 
the characters of medullary cancer ; it varies in vascularity ; at times, 
either from the large number of small arteries passing through the 
growth, or from the vicinity of a large artery, it puts on the character 
of an erectile or aneurismal tumor; the diagnosis in this case is of great 
importance in reference to treatment, as an erroneous assumption of the 
vascular nature of the disease would, as it has done, lead to the appli- 
cation of ligatures, a proceeding necessarily useless. The epiphysis of 
the long bones, especially of the femur, the tibia, and the humerus, are 
chiefly liable to be affected with medullary carcinoma ; the bones of the 
head and face, the ribs, sternum, and pelvis, are also subject to b* 



CANCER. 



713 



attacked. The fragility which was noticed in the individual case before 
alluded to is a quality often spoken of by authors as associated with 
cancer, without determining or assuming the existence of actual carci- 
nomatous disorganization of the bone; it is also observed in deep-seated 
constitutional affections of a syphilitic, scorbutic, and arthritic character, 



Fig. 393. 



Fig. 394. 





Osteocephaloma of the head of the humerus, with Section of tumor ; upper end and head of hu- 

spontaneous fracture of the shaft. merus destroyed, but cartilage of incrustation 

unaffected. Tumor divided by white vertical 
lines — the periosteum, inside which only were 
the osseous spiculas found. 

and cases are recorded of extreme fragility as a mere result of old age ; 
it is not, therefore, inconsistent to assume that, when accompanying carci- 
nomatous affections, it may be the result of an atrophic state resulting 
from mal-nutrition, without being necessarily accompanied by any actual 
carcinomatous degeneration of the bone. Lobstein, who devotes an 
entire chapter to the consideration of fragility of the bones, relates a 
case of such extreme fragility, in an adult female, that pressure of one 
finger on the head of the tibia caused the bone to give way: the bones 
were very porous, and a white, milky fluid exuded from them when com- 
pressed ; the cartilaginous basis of the bones seemed altogether to have 
disappeared, and, excepting the glutasus maximus, the abdominal mus- 
cles, and deltoid, all the muscular tissue was converted into fat. Roki- 
tansky, who gives a similar case, is of opinion that we have to deal with 
a peculiar form of encephaloid infiltration characterized by the milky 
juice. 

The areolar or gelatiniform variety of cancer is occasionally met with 
in bone. Mr. Stanley records a case affecting the bone of a finger, and 



714 TUBERCLE. 

another occurring in a rib. Rokitansky relates one in which the right 
upper maxilla was the seat of the growth, and where the peripheral 
follicles were developed into large cysts. 

Mr. Stanley describes as malignant a peculiar degeneration of the 
tissue of bone, which appears to commence in the deposit of a yellow 
substance into the medullary canals, changing its color, and converting 
its texture into a soft, crumbling, greasy substance ; small cells filled 
with a glairy fluid, and short white brittle fibres, as well as osseous 
granules and laminae, are found in it ; and as the disease advances, 
which it does with every feature of malignancy, the morbid deposit ex- 
tends beyond the limits of the bone in the form of a circumscribed 
tumor. Subsequently, all the surrounding tissues are involved, the cel- 
lular tissue and the adjoining absorbent glands being converted into a 
similar morbid mass. 

Rokitansky describes fibrous cancer as being occasionally met with in 
bone. A malignant fusion of the bones is described by Lobstein (under 
the designation of osteo-lyosis) as a rare disease, in which to a greater 
or less extent the bone deliquesces, leaving in its place a collection of 
matter of different color and consistency, but not offering any acrimo- 
nious character. The existence of the disease is admitted by Rokitan- 
sky, who adds that it commences in the diploe, where it forms a cavity, 
first inclosed between the compact tables ; these gradually disappear, 
leaving an irregular gap, which is covered by the periosteum, destined 
in its turn to become involved ; in this way a bladder is formed, which is 
filled with gelatinous fluid. It is commonly combined with the develop- 
ment of cancer in the internal organs. 



TUBERCLE. 

The presence of tubercle in bone is an undoubted pathological fact, 
but its frequency has been over-estimated by some authors, as it has 
been underrated by others. In the former case, the error has arisen from 
every evidence of osseous disease in scrofulous subjects having been 
regarded as actually resulting from the deposit of tubercular matter in 
the bone, and from concrete pus having produced appearances closely 
resembling those presented by tubercular matter. In a question of this 
kind the microscope must solve the doubt; the high authority of Lebert 1 
on pathological microscopy justifies our giving the following extract from 
his remarks on tuberculization of bone : 1. When the areolar structure 
of the spongy tissue of bone is yet well preserved, and its meshes filled 
with pus, which from having no vent becomes concrete, it is apt to re- 
semble yellow cheesy tubercle ; when a portion of the fatty matter of 
the medulla becomes mixed with this cheesy substance, the latter offers 
a somewhat transparent character, so as to resemble gray granulations; 
the microscope, however, will detect nothing but the elements of pus 
and fat. 2. We occasionally meet with abscesses in the middle of a 
bone, surrounded by a fibrous membrane. If the pus is unable to escape 

1 Physiologic Pathologique, vol. i. p. 473. 



TUBERCLE. 715 

by a fistulous passage, it becomes concrete, and then assumes the aspect 
of what has been described under the name of encysted tubercle of bone. 
3. The cavities formed in the vertebrae, in caries of the spine, ordinarily 
contain nothing but a portion of bone more or less detached, surrounded 
by sanious pus. These are to be regarded as osseous ulcers, in -which 
we fail to discover the essential element of tubercular caverns, viz : 
tubercle. 4. It is a common thing to meet with caseous masses occupy- 
ing pouches in front of the seat of vertebral caries, from which fistulous 
passages extend and open into the inguinal folds, or elsewhere. These 
pouches contain a grumous matter, which is nothing but concrete pus 
mixed with particles of bone. 5. M. Lebert denies not only having 
found tubercular matter, in those cases of vertebral caries, in which 
there were no pulmonary tubercles, but states that he has even failed 
to find it in those cases in which several organs presented tubercular 
deposit. 

Rokitansky's and Nelaton's views differ materially from those ex- 
pressed by the author just quoted; and it will remain with future in- 
quirers to determine in how far the limitation given by Lebert is correct. 
Still, the general laws as to the site of osseous tubercle remain the same 
in either case. It affects chiefly the spongy bones, and the cancellous 
portions of long bones. An instance of crude tubercle presenting itself 
in the shaft of a long bone is given by Mr. Hewett in the Pathological 
Reports, 1 which we quote on account of its extreme rarity. The indi- 
vidual, a man aged thirty, had been laboring, for fifteen months previous 
to his admission into St. George's Hospital, under a tumor of the mid- 
dle part of the thigh, supposed at first to be malignant, an opinion which 
was modified when the swelling was somewhat reduced under treatment. 
He died eventually of erysipelas — tubercular deposits were found in the 
peritoneum, kidneys, spleen, and lungs. In the thigh, there was great 
thickening and condensation about the cellular tissue uniting the mus- 
cles, and in that between the muscles and the bone ; the periosteum, also 
much thickened, presented on its free surface a large patch of tubercular 
matter, enveloped in a dense cyst. The bone itself was irregular in 
shape, much hypertrophied, and very hard ; at this part its medullary 
cavity was filled with tubercular matter, surrounded by gray semi-trans- 
parent lymph, presenting very much the appearance of the well-known 
granule of the lung. 

According to the prevailing views, tubercle commonly occurs in bone, 
as the yellow opaque tubercle deposited in the cancelli, and inducing a 
gradual absorption of the bony septa, so as to lead to the formation of 
larger accumulations; this deposit is liable to softening, by being mixed 
with the products of inflammation, and is thus converted into a scrofu- 
lous abscess, surrounded by what Rokitansky terms a lardaceo-callous 
cyst, "which," he says, "is in fact the tissue surrounding the softening 
tubercle, infiltrated with lardaceo-gelatinous material." If the tuber- 
cular matter does not soften it becomes cretified; we must attribute the 
chalky substance often found in the cancelli, to a retrograde process of 
this kind. We should be disinclined to admit, to the letter, Mr. Stanley's 

1 Report of the Pathological Society, 1850-51, p. 147. 



716 VASCULAR TUMORS. 

statement, that no reproductive process ever ensues upon the destruction 
of bone by scrofulous disease ; the sluggishness of scrofulous affections 
of bone is notorious, and undoubtedly in the majority of instances, 
■whether the destructive process affects the shaft of a long bone, or the 
cancellar structure of a vertebra, the cure is only wrought with a loss 
of substance giving rise to some deformity. One of the most familiar 
instances is that variety of spinal curvature known as Pott's malady, in 
which the scrofulous destruction of one or more bodies of vertebrae in- 
duces a projection backwards of their spines, and a shortening of the 
column. The adjoining soft parts are often extensively involved and 
secondary effects produced, which do not at first sight appear connected 
with the original malady; thus in scrofulous caries of the spine, abscesses 
form in the surrounding cellular and muscular tissues, which may point 
in the lumbar, sciatic, or inguinal regions, giving rise to lumbar or psoas 
abscesses, or, in the case of scrofulous disease of the hip-joint, we have 
necrosis extending to the pelvis, or sinuses burrowing down to the popli- 
teal regions. 

VASCULAR TUMORS. 

Tumors of a vascular character are occasionally met with in bone, 
resembling those composed of erectile tissue, or rather of a congeries 
of bloodvessels, in soft parts. Mr. Stanley describes a tumor of this 
kind that fell under his observation, as bearing a close resemblance to 
certain naevi consisting of dilated bloodvessels, with a fibrous tissue 
occupying their interstices ; hence, in a section, the tumor presented a 
cribriform appearance, the orifices being apparently those of divided 
bloodvessels. Mr. Stanley regards it simply as a local disease, curable 
by removal of the affected part; Rokitansky believes that it is of cancer- 
ous origin, from having met with cancer in other parts of the skeletons 
in which it occurred. This tumor must not be confounded with those 
enlargements of the bone which are produced by an accumulation of 
blood, owing to rupture of the bloodvessels and consequent hemorrhage 
into the cancelli, or between the periosteum and the bone. Cruveilhier, 
who inclines to the same view as Rokitansky, gives delineations 1 of a 
remarkable case, in which a lady, set. thirty-eight, of a good constitu- 
tion, and without hereditary taint, the mother of eight children, pre- 
sented a dozen tumors of the size of a walnut, situated on the head. 
They were soft, and pulsated; the beats were isochronous with that of 
the pulse, and were accompanied with a blowing noise, similar to one 
heard at the aorta. There were several similar tumors in other parts 
of the body, but those of the head only proved after death to belong to 
the bones. They exhibited on section a filamentous areolar structure 
filled with blood; the destruction' of the bone penetrated to the dura 
mater; the absorption of the osseous tissue resembled that produced by 
aneurism; on the external surface there was evidence of an attempt at 
repair, in the shape of osseous vegetations. Cruveilhier is of opinion 
that in this case the vascular development took place mainly at the ex- 

1 Anatomie Pathologique, torn. ii. livr. xxxiii. pi. iv. 



VASCULAK TUMORS. 717 

pense of the arterial system ; he thence infers a general law that there 
are two kinds of erectile tumor, one of a venous, the other of an arterial 
character. He regards the latter as analogous with fungus hsematodes. 

Mr. Stanley describes a sanguineous tumor of bone, always originat- 
ing in the cancellous texture, by blood being effused into it, and causing 
a gradual enlargement of the cells and absorption of the septa. The 
walls of the bone are thus gradually expanded into a globular cyst of 
varying thickness and extent. According to the stage of the disease 
the blood is found in cells, intersected by fibres or laminae and fibres, 
the remains of the original fabric of the bone; or, in a more advanced 
stage, in a single cyst. A feeling of fluctuation may be thus produced, 
and gradual ulceration may give rise to a discharge externally. These 
tumors occur chiefly in the articular ends of bones, and most fre- 
quently within the condyles of the femur or head of the tibia. A form 
of sanguineous tumor of the head, met with in infancy as a result of 
the pressure exerted upon the cranial bones during parturition, and 
known by the term cephalhaematoma, has given rise to much discussion, 
as the symptoms have been variously explained by different observers. 1 

It consists of an effusion of blood between the pericranium and the 
bone, and is most commonly met with on one of the parietal bones. 
Rare cases are recorded of an internal cephalhaematoma, in which the 
extravasation took place between the dura mater and the bone. All 
authors are agreed that external cephalhaematoma occurs most frequently 
on the right side. Bednar (quoted by Mr. Willshire) found, that of 74 
examples, 40 were on the right, 22 on the left, 6 over each parietal 
bone, 4 on the occipital, 1 over both parietals, and the occipital, and 
1 over the frontal bone, the latter being the smallest. 

Older writers have regarded it as depending upon an essential disease 
of the bone, owing to the hard ring bounding the tumor, and inducing 
the impression that the bone has been excavated. A considerable dif- 
ference of opinion still exists as to the exact rationale of its production, 
and more particularly as to the point of the maternal organs at which 
the pressure is effected that produces the tumor ; but most observers 
agree as to its being immediately connected with hemorrhage from the 
torn vessels ; the blood coagulates, and a reparative process is set up, 
which causes a fibrinous pad at the circumference, which, in its turn, 
may ossify, if absorption does not ensue rapidly. Whether or not a 
diseased state of the foetal bloodvessels may predispose to the affection, 
is a question which is answered in the affirmative by some, while it is 
denied by others ; it is certain that the chief argument of a primary 
disease of the bone is destroyed by the more careful analysis of cases by 
recent observers; showing the ring of bone either not to exist at all, or 
else to be a secondary ossification of the coagulum, accompanied by an in- 
flammatory process. This, according to Rokitansky, commences at the 
margin of the denuded part, and produces the deposit of bony matter in 
the form of a velvety or finely filamentous osteophyte. It appears that; 

1 A good resume of their opinions is given by Dr. Willshire, in the tenth volume of tho 
British and Foreign Medico-Chirurgical Review, July, 1852, p. 6. 



718 CYSTS. 

artificial interference commonly becomes necessary for the removal of 
the coagula, suppurative inflammation being otherwise liable to set in 
and give rise to carious destruction of the bone. 



CYSTS. 

Cysts occur very rarely in bone. A very remarkable instance is 
described by Mr. Keate, 1 in which a large tumor in the frontal bone of 
a young woman, set. 18, was formed by the development of hydatids 
between the plates of the bone. Frequent attempts to destroy the cyst 
and its contents, by escharotics, after removal of a portion of the ex- 
ternal osseous sheath, failed ; and the constant sprouting out of fresh 
hydatids at last induced Mr. Keate to saw off the entire tumor, after 
which the girl completely recovered. The diameters of the exposed 
surface were four and a half by four inches. In the very compact and 
hard bony substance, forming the base of the tumor, were five or six 
cells containing hydatid cysts. It appears that from these cells the 
hydatids were constantly regenerated, forcing their way into the large 
cavity of the tumor, and yielding to no treatment, as the remedies 
failed to destroy the matrix from which they pullulated. 

Mr. Stanley quotes some cases from his own experience, and that of 

Fig. 395. 




Osteocystoma, of large size ; occupying lower end of femur. — Prep, in University Museum. 

other observers, from which it appears that the bones of the skeleton 
are all equally liable to be attacked. The development of hydatids 

1 Medico-Chirurgical Transactions, vol. x. p. 278. 



MOLLITIES OSSIUM. 719 

induces a gradual, painless expansion of the bone, which may thus be- 
come perforated and allow of an escape of the hydatids. The cavity of 
the bone in which the hydatids form is lined by an adventitious cyst, 
and this is said to be liable to excite inflammation in the surrounding 
bone, as well as to induce purulent products in the cysts. Cysts of this 
description often contain matter, to the naked eye, absolutely identical 
with laudable pus, which, however, under the microscope, exhibits none 
of the characters of pus. We have recently examined two hydatid cysts 
of this kind, removed from the livers of two patients of St. Mary's Hos- 
pital, on which the bright green, semifluid contents showed no trace of 
pus, but granular matter, granular corpuscles, varying much in size and 
shape, the granules being highly refracting particles of oil, much green- 
ish-colored oil and echinococci, entire or in parts. Had these cysts been 
found to contain pus, where there was no trace of inflammatory action 
in the vicinity, it would have been difficult to reconcile its presence with 
the usual theory of suppuration, the more so as the cyst envelop cannot 
be shown to contain any vessels. It is probable, therefore, that, in 
those cases in which bone hydatids present puriform contents, these 
must be interpreted according to the views suggested by the above ob- 
servations. 

MOLLITIES OSSIUM. 

Mollities ossium, osteomalacia, or malacosteon, is a disease regarding 
which the views of authors differ; some treating it as essentially distinct 
from other known osseous maladies, some as a form of atrophy ; others, 
again, as identical with rachitis, except in that it attacks adults instead 
of children. The rarity of the disease is one great obstacle to our ar- 
riving at a satisfactory conclusion ; but, so far as the evidence reaches 
that we have been able to examine, there appears to be every reason 
for regarding it as much deserving of a separate place in pathology as 
any disease of the bones which we have investigated. 

The disease consists, as the term indicates, essentially in a softening 
of the bones, brought about by an absorption of the earthy matter, and 
the substitution of a large quantity of fat. It is an entire perversion of 
the process of nutrition, in as far as regards the skeleton, the earthy 
phosphates being eliminated from the system by the kidneys, while a 
deposit of fat takes place into the cartilaginous matrix, a process which 
necessarily induces great pliability and fragility of the bones. As the 
bones of the trunk are especially liable to be attacked, the individual 
affected becomes reduced in size from the collapse of the vertebral 
column. A tall subject may thus be converted into a dwarf; an instance 
of which we had an occasion of seeing in the Clinique of Professor 
Kilian, of Bonn. The individual was a married woman, whose stature 
had diminished in this manner, and was doubly interesting from having 
in this condition become the subject of a successful Cesarean operation. 
It was subsequent to her recovery from this ordeal that we saw her, and 
that she was supposed to be again pregnant. Dr. Greenhalgh enabled 
us recently to examine a similar instance, in which the disease was also 
followed by contraction of the pelvis, rendering the Cesarean section 



720 



MOLLITIES OSSIUM. 



necessary. Adults, and especially females, are the subjects of the 
malady. It attacks women chiefly after they have commenced child- 
bearing. Mr. Curling 1 has collected sixteen cases, thirteen of which 

Fig. 396. 




Section of a femur from a lady set. 30, affected for some years with mollities ossium. The walls of the bone 
are thin, soft, and flexible : the place of its medullary and cancellous tissue is occupied by soft, jelly-like, 
transparent fat, of various shades of yellow and pink, some of it deep crimson ; a similar kind of fat appeared 
to be diffused through the proper texture of the walls.— St. Bartholomew's Museum, i. 233. 

occurred in females, and three in males. Eleven were fatal between 
thirty and forty. In none it showed itself before puberty ; but two 
patients were above fifty years of age. Several of them were delivered 
of children during the progress of the complaint. It is not associated 
with any particular lesion of the viscera ; neither can an hereditary or 
idiopathic taint, or diathesis, be traced, by which the peculiar symptoms 
could be explained or referred to a known type. Kilian 2 treats of mol- 
lities ossium as presenting two varieties — the waxy (cereaj, and the 
fragile (fracturosa). In the former, the bones generally, but especially 
those of the pelvis, present a dirty, dark-yellow color. They lose their 
transparency in the middle, while their weight is not much diminished, 
and they become flexible, like wax ; in the second, the bones present a 
snowy whiteness, and a light transparent, open texture, rendering the 
bones so fragile that they give way under the mere pressure of the 
finger. The first kind of bones do not dry clean, but remain greasy ; 
the second dry quickly, and give no greasy feel. Both varieties, ac- 
cording to Kilian, exert the same influence upon the pelvis in regard to 

1 Medico-Chirurg. Trans, vol. xx. p. 336. 

2 Kilian, H. F. Ceitrag zu einer genaueren Kenntniss der allgemeinen Knochener- 
weichung, &c, Bonn, 1829 ; and Die Geburtslehre, &c, vol. ii. p. 367, 1840. 



MOLLITIES OSSIUM. 721 

the distortions that are produced. These he describes as consisting in 
angular deflections of the individual bones, and a mutual approximation 
of the bones in the conjugate and transverse diameters. If Professor 
Kilian's view regarding the two species of the malady be correct, it is 
probable that they would be distinguished by their chemical constitu- 
tion, and this may be assumed as the reason why the chemical analysis 
of the bones affected with osteo-malacia have yielded results so widely 
apart. Thus, in one of the two remarkable cases detailed by Mr. Solly, 1 
the analysis of the affected bone, by Dr. Leeson, showed 100 parts to 
contain 

Animal matter 18.75 

Phosphate and carbonate of lime 29.17 

Water 52.08 

100.00 

The chemical examination of a case (detailed by Dr. Ramsbotham, in 
the Reports of the Pathological Society) 2 by Dr. Garrod, yielded, 

Fatty matter 20.35 

Gelatin yielding matter .58.37 

Carbonate and phosphate of lime, and phosphate of magnesia 21.28 

100.00 

In the former analysis, we see nearly eight parts more earthy matter 
than in the latter; nor can it be objected that the analyses were made 
at different stages of the disease, because, in both instances, the pa- 
tients from whom the specimens were taken had succumbed to the 
malady. The analysis given by Dr. Bostock, 3 reduces the amount of 
earthy matter to a yet lower figure. In a specimen that he examined, 
he found the proportions to be, in one hundred parts of bone: — 

Jelly and oil 22.5 

Cartilage 57.25 

Earthy matter 20.25 

Mr. Stanley quotes an analysis of Dr. Bostock's, in which the constitu- 
tion of the entire bone was, in 100 parts of oil, about 67 ; of membrane, 
about 20 ; of earthy salts, about 11. 

The microscope shows the structure of the bone altered ; the corpus- 
cles and their canaliculi having lost their earthy contents, are empty 
and transparent, and only faintly visible ; while the Haversian canals 
are unnaturally enlarged. Dr. Hall Davis, in his report of the micro- 
scopic appearances of the case of Dr. Ramsbotham, above quoted, states 
that, besides fat and blood, he found nucleated cells. Rokitansky ap- 
pears to consider it allied to malignant disease, but does not mention 
the presence of compound corpuscles ; it therefore yet remains to deter- 
mine, as far as the microscope can do it, the relation to cancer ; and it 
seems probable that, while we may thus establish a true fatty degenera- 
tion of bone, we may also prove that many cases of mollities ossium 

1 Medico-Chirurgical Transactions, vol. xxvii. p. 435. 

2 Reports, &c, 1847-48. 

3 Medico-Chirurgical Transactions, vol. iv. p. 38. 

46 



722 THE MEDULLA. 

Fig, 397. 




I 

Bone-corpuscles; a, in the normal state; b, enlarged, as in mollities ossium. — Dalrymple. 

are essentially primary cancer of the skeleton. We have ourselves 
spoken of a case of this kind (p. 712). 

In a well-marked instance of mollities ossium, of which the history 
was given to the Medico-Chirurgical Society by Dr. T. K. Chambers, 1 
and which occurred in a female set. twenty-six, the bones throughout 
the system were soft and yielding, so that a sharp knife could readily 
pass through them. A portion submitted to our examination, which 
was removed from the tibia, resembled rather a piece of muscle than of 
bone. The periosteum was entire, and it was only in connection with it 
that a few minute spicule of bone could be found. In these, there was 
a faint trace of the bone-corpuscles, but they were filled with reddish 
oil. The remaining tissue consisted of large, transparent oil-vesicles, 
and minute globules of reddish oil. The muscular tissue examined, 
though to the naked eye healthy, was entirely deprived of its normal 
structure, and converted into reddish corpuscles, of from T §^fj^ of an 
inch in diameter, Intermingled with large oil-vesicles. We saw nothing 
at all resembling the character of malignant growth. 



THE MEDULLA. 

The medulla undoubtedly participates in the nutritive and morbid 
processes affecting the bones individually or generally ; and we have 
already had occasion to see that, in several of the diseases of the latter, 
changes in the medulla form an essential constituent of the malady ; as 
in encephaloid cancer, or mollities ossium. It is yet to be determined 
in how far the medulla is liable to become primarily affected. It varies 
in consistency according to the vigor of the individual; while in drop- 
sical and phthisical cases we find it thin and serous, or yellow in icterus, 
or very scanty in ivory condensation of a bone ; it exhibits greater 
firmness, and a richer pink hue, in habits tending to an inflammatory 
character. Lobstein states that he has repeatedly verified the exist- 
ence of inflammation of the medulla, but invariably associated with 
inflammation of the reticular tissue of the bone. Its color, in this case, 
resembled that of kermes, and its density that of fibrin. He observed 
it not only in the medulla contained in the diaphyses, but also in the 
epiphyses of cylindrical, in the diploe of flat bones, and in the reticular 
substance of certain bones at the base of the cranium, such as the basilar 

1 Medical Times and Gazette, March 25, 1854. 



THE MEDULLA. 723 

portion of the occipital and of the body of the sphenoid. In the latter 
bone, he states that he has met with this condition more frequently 
than in any other region ; a remark that deserves attention in reference 
to certain observations of other authors regarding the constriction of 
the foramen magnum in producing epilepsy, and the enlargement of the 
odontoid process in connection with chorea. The real seat of inflam- 
mation in bone, as Rokitansky remarks, is the membrane that lines its 
cavities ; it is, therefore, fair to infer that, in all diseases dependent 
upon the state of the vascular system, whether of an ordinary or of a 
malignant character, the medulla is affected coincidently with, if not 
previously to, the bony tissue itself. 



INDEX 



Abscess, metastatic, 355 
Acari scabiei, 214 

folliculorum, 214 
Acephalocyst, or hydatid, 221 
Albumen of serum, quantitative variations 

in, 68 
Albuminosis, 160 
Alimentary canal, pathological anatomy of, 

447 
Alternating calculus, 584 
Anaemia, causes, symptoms, results, 73, 81, 

85, 87 
Anatomy, morbid, definition of, 33 
Anchylosis, 675 
Aneurism, 344 

by anastomosis, 366 

of the heart, 308 

varicose, 351 
Aneurismal hypertrophy of heart, 304 
Angiectoma, 175 
Anus, imperforate, 501 

lacerations of, 501 

prolapsus, 485 
Apoplexy, 251 

cerebral, 251 

sequelae of, 253 

of heart, 301 

of lungs, 402 

of spinal meninges, 271 
cord, 275 
Appendix vermiformis, morbid states of, 500 
Aphthae, 449 
Arachnoid, pathological anatomy of^230 

cysts in, 245 

effusion beneath, 231 

granulations, 232 

hemorrhage into, 232 

inflammation of, 234 
Arachnitis, cerebral, 234 

spinal, 272 
Arteries, morbid anatomy of, 332 

aneurism, 344 

atheroma, 338 

fibrinous deposits in, 333 

inflammation of, 332 

ossification of, 341 
Arteritis, acute, 332 

chronic, 337 
Arthritis, chronic rheumatic, 676 



Ascaris lumbricoides, 215 
vermicularis, 216 

Asphyxia, production of, 74 

Atelectasis pulmonum, 397 

Atheroma, 340 

Atrophy of brain, 261 

of coats of stomach, 466 

general account of, 162 

of heart, 310 

from inflammation, 141 

of nerves, 280 

of spinal cord, 274 

of tongue, 454 

of valves of heart, 320 



B 



Bacony deposit, 517 

Bile, morbid conditions of, 527 

Biliary calculi, 529 

matters in blood, 78 

passages, abnormal conditions of, 525 
Bladder, morbid anatomy of, 564 

cancer of, 569 

congenital malformations of, 564 

congestion of, 567 

contraction of, 565 

dilatation of, 564 

displacements of, 566 

diverticula, 565 

hypertrophy of muscular coat, 566 

inflammation of, 567 

inversion, extrophy, 564 

malformations of, 564 

pericystitis, 569 

sacculation, partial dilatations of, 565 

softening of, 569 

tubercle of, 569 
Blood, morbid states of, 50 

determination of, 99 

erases of the, 151 
Bloodvessels, morbid anatomy of the, 331 
Bones, pathology of the, 681-684 

adventitious growths of, 704 

cancer of, 712 

caries of, 688 

cysts of, 719 

exostosis of, 706 

fibrous growths, 710 

inflammation of, 684 

malformations of. 681 



'26 



INDEX. 



Bones — 

necrosis, 690 

osteophyte, 708 

rachitis, 695 

softening of, 685-719 

tubercle of, 714 

tumors of, 711 

vascular tumors of, 716 
Bothriocephalus latus, 217 
Brain, pathology of, 247 

atrophy of, 261 

cancer of, 264 

circulation in, 247 

congestion of, 249 

cysts of, 266 

fatty tumors of, 266 

fibroid tumors of, 266 

hemorrhage of, 238, 250 

hydatids of, 266 

hypertrophy of, 260 

induration of, 259 

inflammation of, 255 

melanosis of, 265 

morbid growths in, 262-266 

oedema of, 255 

softening of, 254-256 

state of, in lunatics, 249, 261 

suppuration of, 257 

tubercle of, 262 

tumors of, 266 
Bronchial tubes, pathological anatomy, 384 

calcareous concretions in, 392 

constriction of, 388 

dilatation of, 389 

hemorrhage, 384 

inflammation of, 386 

polypi, 387 

tubercle of, 391 
Bronchitis, 386 
Bronchiectasis, 389 
Bronchocele, 539 
Bursse, inflammation of, 679 

melon-seed bodies in, 680 

suppuration of, 679 

thickening of walls of, 679 



Calculi, biliary, 529 

of the salivary ducts, 532 
urinary, 581 

alternating, 584 
calcareous, 584 
cystic oxide, 582 
fibrinous, 584 
fusible, 583 

lithate of ammonia, 582 
lithic acid, 582 
oxalate of lime, 582 
phosphatic, 583 
prostatic, 603 
xanthic oxide, 584 
Cancerous tumors, 187 

changes in, 208 
development of, 208 



Cancerous tumors — 

diagnosis of, 196 
diffusion of, 209 
origin of, 207 

primary and secondary, 209 
saponification of, 209 
varieties of, 190 
Cancer of the bladder, 569 

in the brain, 264 

of bone, 712 

cells, 198 

chimney-sweepers', 598 

colloid, 192 

epithelial, 194 

of gums, 448 

in the heart, 311 

of intestines, 499 

of the kidneys, 560 

of the liver, 522 

of the lungs, 431 

of lymphatic glands, 371 

melanoid, 190 

in the oesophagus, 460 

in the ovaries, 650 

of the pancreas, 332 

of the penis, 606 

of the pericardium, 294 

of the peritoneum, 464 

of the pleura, 445 

of the spleen, 538 

of the stomach, 476 

of the supra-renal capsule, 542 

of the testes, 594 

of the thyroid gland, 541 

of the tongue, 453 

of the urethra, 573 

of the urinary passages, 563 

of the uterus, 624 

of the vagina, 613 
Capillaries, morbid anatomy of, 365 
Capillary phlebitis, 365 
Carbonate of lime calculus, 584 
Carbonic acid, poisonous effects of, 73 

in blood, 73 
Cartilage, atrophy of, 667 

hypertrophy of, 666 

ulceration of, 667 
Carditis, 296 
Caries, 688 

of teeth, 455 
Cartilages, loose in joints, 665 
Cavities in lungs, 425 
Cephalhematoma, 225 
Chancres, 605 

Chimney-sweepers' cancer, 598 
Cholesteatoma, 174 
Chordee, 570 

Choroid plexus, morbid anatomy of, 244 
Circulation, organs of, pathological anatomy 

of, 287 
Cirrhosis of liver, 512 
Circocele, 650 

Clitoris, morbid conditions of, 609 
Colloid cancer, 192 
Contractility disordered, 38 



INDEX. 



727 



Congestion, causes, effects, 92, 96 
Coronary arteries, in fatty degeneration of 

heart, 300 
Corpuscles of the blood, 50 
Crases of the blood, 151 
Croup, 378 

Croupous exudation, 131 
Cyanosis, 326 
Cystic oxide calculus, 582 
Cystitis, 567 
Cysts, arachnoid, 245 

in brain, 266 . 

in bone, 718 

compound, 183 

in gall-bladder, 530 

in heart, 311 

in kidneys, 555 

in labia, 608 

in liver, 520 

in lungs, 433 

in ovaries, 645 

in pancreas, 532 

in pleura, 445 

in spinal cord, 277 

in spleen, 537 

in testes, 594 

in tongue, 453 

in urinary passages, 563 

in uterus, 623 
Cysticercus cellulosa, 218 
Cystoid tumors, 181 
Cysto- sarcoma, 186 



D 



Degenerations, fatty, fibrous, calcareous, 

163, 165 
Dental caries, 455 

necrosis, 457 

periosteum, inflamed, 458 

pulp, diseases of, 458 
Derangement, functional, 35, 38 
Diathesis, 36 

Diphtheritic inflammation, 126 
Disease, organic, 36 

functional, 38 
Dislocations, effects of, 678 
Distoma hepaticum, lanceolatum, oculi hu- 

mani, 216 
Diverticula of the bladder, 565 

intestinal, 480 

of the trachea, 382 
Dropsies, 111-114 

composition of effusions in, 116 
Dropsy of the chest, 441 

ovarian, 645 
Ductless glands, abnormal condition of, 533 
Ductus communis choledochus, inflamed, 525 

obstructed, 527 
Dura mater of cerebrum, diseased conditions 
of, 225 

of spinal cord, diseased conditions of, 
269 

cancer of, 228, 269 

fibroid tumors of, 227 



Dura mater — 

inflammation of, 226 

malformation of, 228 

ossification of, 228 

tubercle of, 269 
Dysentery, morbid changes in, 494 



E 



Echinococcus hominis, 219 

Elephantiasis of scrotum, 597 

Emphysema, vesicular, of lungs, 394 

Empyema, 439 

Encephalitis, 255 

Enchondroma, 176, 704 

Encephaloid cancer, 187 

Encysted tumors, 181 

Endocardium, morbid anatomy of, 313 

Endocarditis, 313 

Enlargement of parts from inflammation, 

141 
Enteritis, 487 
Entozoa, 363-372 

of glands, 372 

in veins, 364 
Epidermic and epithelial tumors, 170 
Epididymitis, 591 
Epilepsy, 267 
Epiglottis, morbid anatomy of, 374 

inflammation of, 374 

oedema of, 376 

ulceration of, 375 
Epithelial cancer, 194 

tumors, 170 
Epulis, 448 
Exostosis, 179 
Extractive matters of blood, variations in, 

69 
Exudation-globule, 138 



F 



Fallopian tubes, diseases of, 642 
Fatty degeneration, 163 

of choroid plexus, 246 
of heart, 298 
of liver, 515 
Fatty tumors, 172, 266, 453, 476 
Fauces, pathological anatomy of, 447 
Fibroid tumors of dura mater, 227 
of ovaries, 649 
of uterus, 619 
Fibrous degeneration, 164 

tumors, 166 
Fibro-cystic tumors, 168 
fatty tumors, 168 
Fibrin, quantitive, qualitative variations in, 

metamorphoses, 56 
Fibrinous crasis, 151 

deposits in lungs, 414 
exudation, 131 
Filaria bronchialis, 215 
medinensis, 215 
oculi humani, 215 
Flux, active or passive, 110 



728 



INDEX 



Foetus, 638 
Formations, new, 167 
Fibrinous calculus, 584 
Fusible calculus, 583 

G 

Gall-bladder, cysts of, 530 

inflammation of, 525 

malformations of, 525 

ulceration of, 526 
Gall-stones, 529 
Ganglions, 680 
Gangrene or mortification, 143 

of heart, 302, 315 

of liver, 512 

of lungs, 415 

of mouth, 450 

of pleura, 442 
Gastritis, 466 

Generative organs, morbid conditions of 
male, 585 
of female, 607 
Glands, lymphatic, carcinoma of, 371 
entozoa of, 372 
melanosis of, 371 
tubercle in, 370 
Glandulse Pacchioni, 232 
Globule, exudation, 138 
Glottis, affections of, 377 
Glomeruli, or granule-cells, 138 
Glossitis, 452 
Granule-cell, 138 
Gums, cancer of, 448 

fibrous tumor of, 448 

polypous tumor of, 448 

vascular tumor of, 448 



II 



Haemothorax, 442 
Haematin, crystals of, 108 
Haematocele, 590 
Haemoptysis, 384 
Haemorrhoids, 361, 502 
Haemothorax, 442 
Heart, morbid anatomy of, 296 

aneurism of, 304-308 

apoplexy of, 301 

atrophy of, 310 

cancer of, 311 

congenital malformations of, 329 

congestion of the, 296 

fatty degeneration of, 298 

dilatation of, 307 

gangrene of, 302, 315 

hydatids of, 311 

hypertrophy of, 303 

inflammation of, 296 

morbid growths in, 311 

ossific deposits in, 311 

rupture of, 301 

tubercle of, 311 

ulceration of, 297 

valves of, morbid states of, 319 



Heart-clot, 316 
Hemorrhage, 106 

into arachnoid, 232 

in the brain, 238, 250 

in the bronchi, 384 

in the ventricles of brain, 238 
Hemorrhagic inflammation, 127 
Hepatic abscess, 510 

ducts, croupy inflammation of, 527 
inflammation of, 526 
knotty tumors of, 525 
pigmentary deposits in, 526 

vein, phlebitis of, 512 
Hepatization of lungs, 405 
Hepatitis, 510 
Hydrocephalus, 237-240 

composition of effused fluid, 243 
Hydrocele, 588 
Hydro-sarcocele, 588 
Hydrothorax, 441 
Hydatids in brain, 266 

in heart, 311 

in lungs, 433 

in spinal cord, 277 
Hydrasmia, 73 
Hydrocele, 588 
Hydrops renalis, 561 
Hymen, abnormal conditions of, 610 
Hypertrophy, 161 

of brain, 260 

of heart, 303 
Hyperaemia, 87, 92, 99 
Hypinosis of blood, 160 



I 

Ichor, 137 

Icterus neonatorum, 519 

Idiosyncrasies, 36 

Idiocy, state of brain in, 261 

Induration, 162 

of brain, 259 

of spinal cord, 276 
Inflammation, 117 
Intestinal canal, morbid anatomy of, 480 

abnormal contents of, 505 

ani atresia, 501 

appendix vermiformis, morbid states 
of, 500 

cancer of, 499 

catarrhal inflammation of, 488 

change of position of, 482 

concretions in, 506 

contraction of, 481 

dilatation of, 481 

diverticula of, 480 

condition of; in dysentery, 494 

false membrane, formation of, in, 491 

fissures of rectum, 502 

gas in, 505 

gelatiniform softening of, 497 

haemorrhoids, 361, 502 

internal strangulation of, 483 

incarcerations of, 482 

inflammation of, 487 



INDEX. 



729 



Intestinal canal — 

invaginations of, 483 
malformations of, 480 
prolapsus ani, 485 
softening of, 497 
tuberculous deposits in, 498 
typhilitis stercoralis, 500 
typhoid process, and ulcers, 492 
wounds and lacerations of, 486, 501 

Intussusception, 484 



Jaundice, 518 
Joints, abscess of, 660 

anchylosis of, 675 

arthritis, chronic rheumatic, 666 

cartilage of, diseased conditions of, 
666 

cartilages, loose, in, 665 

degeneration, pulpy, of synovial 
membrane, 663 

dislocations, effects of, 678 

inflammation of, 659 

ligaments of, diseased conditions of, 
665 

malformations of, 659 

scrofulous disease of, 672 

suppuration and ulceration of, 660 



K 

Keloid tumor, 169 
Kidneys, anaemia of, 545 

abscess of, 546 

adipose tissue around, increase of, 

• 561 

atrophy of, 552 

Bright's disease, 547 

cancer of, 560 

capsule of, inflamed, 561 

congenital anomalies of, 543 

contracted granular, 552 

cystic formation, 555 

degenerative disease of, 547 

enlargement of, 548 

entozoa in, 561 

hemorrhage, 544 

hyperemia of, 547 

inflammation of, 545-547 
of capsule, 561 

tubercle of, 560 



Labia, diseases of, 607 

encysted growths of, 608 
hemorrhagic tumor of, 501 
oozing tumor of, 605 

Lactic acid in the blood, 68 

relation to rheumatism, 7£ 

Laryngitis, 376 

Larynx, inflammation of, 376 
ossification of, 380 
ulceration of, 380 



Lateritious sediment of urine, 578 
Leucorrhoea, 612, 627 
Leucocythemia, leukhsemia, 147 
Ligaments of joints, inflammation of, 665 

relaxation of, 665 
Lipomata, 172 
Liquor sanguinis, 56 
Lithate of ammonia calculus, 582 
Lithic acid calculus, 582 
Liver, abscess of, 510 

adventitious growths of, 520 

atrophy, acute yellow, of, 519 

bacony deposit in, 517 

cancerous tumors of, 522 

cirrhosis of, 512 

congestion of, 507 

fatty degeneration of, 515 

fibroid degeneration of, 513 

gangrene of, 512 

in jaundice, 519 

hemorrhagic effusions, 509 

hydatid cysts of, 520 

inflammation of, 510 

lardaceous, 517 

nutmeg condition of, 507 

phlebitis of, 512 

tubercle of, 520 

waxy, 517 
Lungs, morbid anatomy of, 393 

abscess of, 412 

adventitious deposits in, 417 

apoplexy of, 402 

cancer of, 431 

cavities in, 425 

condensation of tissue of, 412 

congestion of, 400 

cysts in, 433 

dilatation of air-cells, 394 

emphysema, vesicular, of, 394 

fibrinous deposits in, 414 

gangrene of, 415 

inflammation of, 405, 415 

oedema of, -399 

tubercle of, 417 
Lymphatics, inflammation of, 368 

varicosity of, 369 
Lymphatic glands, carcinoma of, 371 

entozoa in, 372 

hypertrophy of, 370 

melanosis of, 371 

tubercle of, 370 



M 



Mamma?, female, diseases of, 6-30 
male, diseases of, 657 

Mamma, cancer of, 655 

encysted tumors of, 652 
fibrous tumors of, 654 
hypertrophy of, 651 
inflammation of, 651 
tubercles in, 655 

Mariscee, 502 

Mastoid tumors, 190 

Meatus urinarius, vascular tumor of, 



730 



INDEX. 



Medulla, pathology of, 722 
Melanoid cancer, 190 
Melanosis, 171 

in the brain, 265 

of glands, 371 

of spinal cord, 270 
Melanotic tumors, 171 
Meningitis, cerebral, 235, 239 

spinal, 272 
Metastatic abscesses, 355 

of lungs, 413 
Metro-phlebitis, 632 
Mole, vesicular, 638 
Mollities ossiura, 719 
Morbus Brightii, 547, 558 
Mortification, 143 
Mouth, aphthse of, 449 

cancerous tumors of, 448 

diphtheritic exudation of, 448 

epulis, 448 

gangrene of, 450 

inflammation of, 447 

malformations of, 447 

vascular tumors of, 448 
Muco-purulent matter, 137 
Mucous encysted tumors, 182 
Mucus, 139 
Muguet, 449 
Micoderm of favus, 214 
Myeletis, 275 
Myeloid tumors, 177 

N 
Nsevi, 175 
Necrsemia, 149 
Necrosis, 690 
Nephritis, 345 
Neuroma, 283 

Nervous system, pathology of, 223 
Nerves, pathology of, 279 

atrophy of, 280 

hypertrophy of, 281 

inflammation of, 281 
New formations, 167 
Nutrition, deranged, 46 
Nymphae, diseased conditions of, 609 

enlargement of, 609 



(Edema of brain, 255 

of epiglottis, 377 

of lungs, 399 
(Esophagus, constrictions of, 459 
Oily matters of blood, 70 
Orchitis, 591 

Osseous system, pathological anatomy of, 
681 

tumors, 179 
Osteophyte, 180, 708 
Osteoid tumor, 181, 711 
Ossification of arteries, 341 

dura mater, 228 

larynx, 380 

lungs, 443 



Ossification of — 

trachea, 382 
Ovaries, pathology of, 644 
Ovarian dropsy, 645 
Oxalates, deposits of in urine, 580 
Oxalate of lime calculus, 582 
Oxalic acid in blood, 79 



Pacchionian bodies, 232 

Pancreas, abnormal conditions of, 531 

atrophy of, 531 

cancer of, 532 

dilatations of duct of, 532 

fatty degeneration of, 532 

hypertrophy of, 531 

inflammation of, 531 
Parasites, animal, vegetable, 213, 214 
Paracentesis thoracis, 440 
Penis, atrophy of, 604 

cancer of, 606 

chancres, 605 

herpes of glans, 605 

hyperemia of, 605 

inflammation of, 605 

malformations of, 604 

paraphymosis, 606 

phymosis, 606 

psoriasis, 605 

ulcers (chancres), 605 

warts, 606 
Peritoneum, cancer of, 464 

chronic thickening of, 464 

inflammation of, 461 

malformations of, 461 

tubercular inflammation of, 463 
Pericarditis, 290 
Pericardium, absence of, 289 

air in, 294 

carcinoma of, 294 

fat in, 294 

fibrinous concretions of, 294 

inflammation of, 290 

tubercle of 293 

white patches in, 289 
Pericystitis, 569 
Peritonitis, 461 

puerperal, 633 
Periosteum, morbid states of, 682 
Peyerian patches, diseased condition of, 489- 

491 
Pharynx, cancer of, 460 

dilatation of, 459 

fibrous tumors of, 460 

inflammations of, 459 

malformations of, 459 

softening of, 460 
Phlebitis, 353 

uterine, 632 
Phlebectasis, 359 
Phlebolithes, 363 
Phlegmasia dolens, 633 
Phosphate of ammonia and ma^ne-ia calcu- 
lus, 583 



INDEX. 



'31 



Phosphate of lime calculus, 583 
Phosphates, earthy, deposits of, from urine, 

579-581 
Phosphoric acid in urine, 579 
Pia mater, diseased conditions of, 230- 

236 
Piles, 361 

Pituitary body, morbid anatomy of, 267 
Placenta, diseases of, 636 
Plastic exudation, 131 
Phthisis, tubercular, 417 
Plethora, causes, consequences, 88-90 
Pleura, adventitious products of, 443 

cancer of, 445 

cysts in, 445 

empyema, 439 

gangrene of, 442 

hemothorax, 442 

hydrothorax, 441 

inflammation of, 434 

pneumothorax, 441 

tubercle of, 444 
Pleuritis, 434 
Pneumopericardium, 294 
Pneumothorax, 441 
Pneumonia, 405 

congestive, 412 

chronic, 415 

lobular, 409 

typhoid, 410 
Pneumatoses, 117 
Poisonous matters in blood, 79 
Polypi in the heart, 361 

of rectum, 502 

of uterus, 622 

of vagina, 613 
Portal vein, inflammation of, 357 
Pregnancy, diseases of, 635 

extra uterine, 641 
Prolapsus ani, 485 

uteri, 617 
Prostate gland, abscess of, 602 
atrophy of, 599 
calculi of, 603 
cancer of, 602 
concretions in, 603 
cysts of, 603 
fibrous tumours of, 602 
hypertrophy of, 599 
inflammation of, 602 
tubercle of, 602 
ulceration of, 602 
Puerperal diseases, 629 

fever, 629 

inflammations, 629 
Pulmonary abscess, 412 

apoplexy, 402 

congestion, 400 

tubercle, 417 
Pulmonic symptoms in typhoid and typhus 

fever, 388 
Pus, 133 

in the chest, 439 
Pyaemia, 144, 355 
Pyelitis, 562 



R 



Rachitis, 695 

Ranula, 182 

Rectum and anus, lacerations of, 501 

Recurring fibroid tumors, 169 

Red corpuscles of blood, 50 

Reflex action, 44 

Renal abscess, 546 

hemorrhage, 544 
Respiratory organs, morbid anat. of, 373 
Rheumatic arthritis, chronic, 666-676 
Rickets, 695 



Salts of blood, variations in, 72 
Salivary concretions, 532 

ducts, dilatation of, 532 
fistulae, 532 

glands, abnormal conditions of, 531 
Sanies, 137 

Sarcomatous tumors, 185 
Sarcoptes hominis, 214 
Sciatica, 279 
Scirrhus, 190 

Scrofulous inflammation, 127 
Scrotum, elephantiasis, 597 

epithelial cancer of, 598 
fibrous growths of, 599 
hypertrophy of, 597 
melanotic cancer of, 599 
Secretion, deranged, 46 
Secondary abscesses, 355 
Sensibility, disordered, 41 
Serotin, 71 

Serum, organic constituents of, 68 
Sinuses of brain, inflammation of, 358 
Softening, 162 

of brain, 254-256 
of heart, 298 
Solanoid tumors, 190 
Spaneemia, 81 
Spinal column, diseases of, 673 

cord and membranes, pathology of, 
268-274 
arachnitis, 272 
atrophy of, 274 
apoplexy of, 271-275 
cartilaginous deposits on menin- 
ges of, 273 
congestion of, 274 
cysts of, 277 
hyperesthesia of, 277 
induration of, 275 
inflammation of, 275 
ossific deposits in meninges of, 

273 
softening of, 276 
curvatures, 674, 698-701 
Spleen, absence of, 533 
anaemia of, 534 
cancer of, 538 

changes in form, place, and size, 533 
chronic thickening of capsule of. 537 



732 



INDEX. 



Spleen — 

cysts of, 537 

enlargement of, 535 

fibrinous deposits in, 534 

hyperemia of, 534 

hypertrophy of, 535 

inflammation of, 534 

purulent deposits in, 534 

rupture of, 533 

tuberculous deposit in, 537 

wounds of, 533 
Steatoma, 173 

Stenosis of bronchial tubes, 388 
Stomach, atrophy of coats, 466 

abnormal contents of, 480 

cancer of, 476 

caustic fluids, effects of, on, 470 

croupy exudation in, 470 

cysts of, 476 

dilatation of, 465 

displacements of, 466 

fatty change of coats, 476 

fibroid change of coats, 476 

hemorrhagic erosion of, 474 

inflammation of, 466 

malformations of, 465, 469 

mammillation of, 467 

perforation of, 472 

softening of, 474 

tubercle of, 476 

tumors of, 476 

ulceration of, 471 

variations in shape and size, 465 
Stomatitis, 450 
Stricture of urethra, 571 
Strongylus gigas, 216 
Supra-renal capsules, morbid conditions of, 

541 
Suppuration, 133 

of brain, 257 
Sympathetic system, pathology of, 284 

neuroma of, 286 
Synovitis, 659 

Synovial membrane, diseased conditions of, 
659 

pulpy degeneration of, 663 



Taenia solium and lata, 216 
Teeth, caries of, 455 

inflammation of periosteum of, 458 

malposition of, 455 

necrosis of, 457 

pulp of, diseases of, 458 
Telangiectasis, 366 
Testes, absence of, 585 

atrophy of, 586 

cancer of, 594 

cysts in, 594 

hematocele, 590 

hydrocele, 588 

inflammation of, 591 

of tunica vaginalis, 587 

loose bodies in, 596 



Testes— 

malposition of, 585 

non-descent of, 585 

purulent deposits in, 593 

tubercle of, 593 

varicocele, 596 
Tetanus, 268, 282, 285 
Textural changes, 161 
Thyroid gland, absence of, 538 

cancer of, 541 

congenital development of, 538 

dilatation of vessels of, 540 

enlargement of, 539 

inflammation of, 539 

tubercle of, 541 
Thymus, absence of, 541 

hypertrophy of, 541 

inflammation of, 541 

tuberculosis of, 541 
Tonicity, disordered, 39 
Tongue, atrophy of, 454 

cancer of, 453 

cysts of, 453 

fatty tumor of, 453 

hypertrophy of, 453 

inflammation of, 452 

tubercles of, 452 

ulceration of, 452 
Tonsils, inflammation and hypertrophy of, 

454 
Trachea, pathology of, 380 

extraneous matter in, 382 

hyperemia of, 380 

inflammation of, 381 

ossification of, 382 

ulceration of, 381 
Trismus neonatorum, 272, 335 
Trichina spiralis, 215 
Tricocephalus dispar, 215 
Tubercle, 153 
Tuberculous crasis, 153 

deposition, 131 

diathesis, 153 

and scrofulous matter, identity of, 
157 
Tubercular meningitis, 239 
Tumors, cancerous, 189 

cystoid, 181 

encysted, 181 

epidermic, 170 

epithelial, 170 

fatty, 172 

fibrous, 167 

keloid, 169 

mastoid, 190 

melanotic, 171 

myeloid, 177' 

mucous encysted, 182 

osseous, 179 

osteoid, 181 

recurring fibroid, 169 

sarcomatous, 185 

vascular, 174 
Typhoid ulcers, intestinal, 492 
Typhilitis stercoralis, 500 



INDEX, 



733 



u 

Ulceration, 142 

of epiglottis, 375 
of heart, 297 
of larynx, 380 
of trachea, 381 
Ulcer, typhus, 492 
Umbilical vein, inflammation of, 356 
Ureters, distended, 561 
Urethra, cancer of, 573 

contraction of, 570 
dilatation of, 570 

female, morbid condition of, 573, 609 
inflammation of, 570 
lacerations of, 570 
malformations of, 570 
stricture of, 571 
tubercle of, 573 
Urea, 577 

Uraemia, different forms of, 76 
Urethritis, 571 
Uric acid in blood, 76 

crystal deposits of, 577 
or xanthic oxide calculus, 584 
Urinary apparatus, morbid anatomy of, 543 
calculi, 581 

passages, anomalous conditions of, 
561 
cancer of, 563 
congenital anomalies, 543 
cysts of, 563 
deposits in, 577 
dilatation of, 561 
hemorrhages of, 544 
inflammation of, 562 
malformations of, 561 
tubercle of, 563 
Urine, acidity of, 574 
albumen in, 575 
anazoturia, 577 
azoturia, 577 
chylous, 575 
coloring matter of, morbid changes in, 

576 
deposits of carbonate of lime from, 58 
of cystic oxide, 580 
of earthy phosphates, 579 
of oxalate of lime, 580 
of phosphates, 581 
of uric acid crystals, 577 
healthy qualities of, 574 
phosphoric acid in, 579 
sugar in, 575 
Uterine phlebitis, 632 
Uterus, absence of, 614 
atrophy of, 615 
cancer of, 624 



Uterus- 



cysts in, 623 
fibrous tumors of, 619 
hypertrophy of, 616 
inversion of, 617 
malformations of, 614, 616 
malpositions of, 616 
polypi of, 622 
rupture of, 618 
tubercle of, 623 
ulceration of os, 627 
virgin, 626 
after parturition, 629 



Vagina, affections of, 610 

cancer of, 613 

chronic thickening of mucous mem- 
brane, 612 

congenital closure, 610 

inflammation of, 612 

lacerations of, 611 

occlusion or stricture of, 611 

polypi of, 613 
Valves, aneurism of the, 324 

diseased conditions of, 319 

fibrous deposits in, 322 

ossific deposits in, 322 

perforation of, 320 
Varix, 359 
Varicocele, 360, 596 
Varicose aneurism, 351 
of heart, 310 

veins, 360 

of labia, 507 
Vascular tumors, 174 
Vas deferens, absence of, 586 
Veins, air in, 364 

carcinomatous matter in, 362 

deposits in, 362 

dilatation of, 359 

entozoa in, 363 

inflammation of, 353 

obliteration of, 362 

rupture of, 359 

umbilical, inflammation of, 356 

varicose, 360 
Vena portag, inflammation of, 357 
Ventricles of brain, effusions into, 238 
Vertebra, diseases of, 673 
Vesicula? seminales, morbid conditions of, 599 
Vessels, new production of, 174 
Virgin uterus, 626 
Voluntary motion, disordered, 43 
Water of blood, varying proportion of, 73 
White corpuscles of blood, 50 



THE END. 











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